1. Annual General Assembly Meeting HomeCare Europe September 26, 2008 CASH FOR CARE & BLACK MARKET IN CARE

2. Content  Part 1: Cash for Care  Part 2: The Black Market in Care

3. PART 1: CASH FOR CARE

4. Content  Cash for care  Personal budgets in Belgium  Persoonlijke-Assistentie Budget (personal assistance budget)  Experiment PGB

5. Cash for Care  Cash for care = money or vouchers given to service users to purchase their own care  Motives for cash for care programmes: Promote choice and autonomy Plug gaps in existing provision Create jobs Promote efficiency and cost savings Promote domiciliary care  Cash for care is often called a personal budget.

6. Personal budgets in Belgium 1.Integratietegemoetkoming (IT) (allowance for disabled people) Allowance for disabled people living in Belgium… who experience difficulties with social integration whose decreased self-efficacy has resulted in increased costs who have an income below a certain limit Not accountable for the way they spend this money Intramural care: 2/3rd of original allowance

7. Personal budgets in Belgium 2.Tegemoetkoming Hulp aan Bejaarden (THAB) (allowance for the elderly) Similar to IT, but meant for people > 65 years old Size THAB allowance < size IT allowance Max. income limit THAB < max. income limit IT

8. Personal budgets in Belgium 3.Vlaamse Zorgverzekering (Flemish Care Insurance) Insurance providing allowances for the cost of non- medical care to people with a severe need for care who…  are receiving home care or informal care at home  are living in a rest home, a rest and nursing home or a psychiatric nursing home Makes home care more payable for people with a severe need for care, who often have high expenses

9. Personal budgets in Belgium 4.Persoonlijke-Assistentie Budget (PAB) (Personal Assistance Budget) Personal assistance budget for people with a disability in Flanders Budget provided to a person with a disability or his or her legal representative for the full or partial underwriting of the personal assistance and its organisation Most similar to the original Dutch personal care budget

10. Persoonlijke-Assistentie Budget  Financial contribution for people with a disability, who are living at home  Advance deposit every 3 months  organise and finance their personal assistance on their own  Assistant can be an employee, self-employed, temporary worker or service provider from an institution or organisation doesn’t need to have certain diploma’s or meet other quality requirements  PAB users are accountable for the way they spend their personal budget Written agreement Cost status report Registered which activities can be paid with the PAB Inspections

11. Persoonlijke-Assistentie Budget  Impact on the home care sector Budget regarded as too small  more attractive to hire “non-qualified” personal assistants Could have impacted the home care sector, but the number of distributed PABs is still limited most PAB-users prefer to rely on both informal and formal care providers (Breda et al., 2004)

12. Persoonlijke-Assistentie Budget  Evaluation of PAB use (Breda et al., 2004) Most PAB users employ > 1 personal assistant Responsible for different tasks Complementary and supplementary relying on both informal and formal care providers Certainty and continuity in care provision Use of services determined mainly by need for care Lower budget and consequently lower need for care  lower use of the (additional) formal circuit Informal support does not seem to lead to a lower user of formal support Persons without a paid informal carer, more rely on the formal circuit for support in mobility, household and other more functional activities than do persons with a paid informal carer

13. Persoonlijke-Assistentie Budget  Evaluation of PAB use (Breda et al., 2004) PAB might enable disabled persons to live at home for a longer period of time Impact on home care sector 1 PAB hr cheaper than 1 hr formal care, but limited substitution of formal circuit causes Flemish government to pay even more Extension rather than a substitution of paid care PAB seems to be generator of questions or demands  financial manageability?

14. PGB experiment  Experiment ‘Persoonsgebonden budget’ Personal budget for people with a disability Start experiment: September 1, 2008 PGB ≠ PAB PABPGB Type of careWay of financing care Limited number distributedShould apply to all people with a disability Broader: choice between a PAB and PGT or a combination

15. PGB experiment  Experiment will need to give insight into the: extent to which the PGB will be the best way to contribute to: self-determination participation to social life quality of life extent to which the PGB could function as the basic way of financing care for all care and/or support providers

16. PART 2: THE BLACK MARKET IN CARE

17. Content  Black care market in Europe  Black market in Italy  Grey market in Austria  Black care market in Belgium?  The PAB and the black market

18. Black care market in Europe  Several European countries have seen a growth in the black or grey market in home care For example, Austria (grey market) and Italy (black market) Growth in provision of privately arranged home care by immigrants

19. Black market in Italy  Demand for social services ↑  public policy inertia  recent growth of a large private care market Low cost labour provided by immigrant women from Eastern Europe, Latin America and some Asian countries  Substantial economic advantage for user  Helps immigrant workers in finding accomodation and obtaining work  +: allows more people to receive home care and to stay at home as long as possible  -: prevents the growth of an Italian organised care market Cost differential too high No adequate controls in place to reduce black care work

20. Grey market in Austria  Pflegegeld = personal budget for elderly and disabled people  Receivers are fully free in the way they spend their pflegegeld Government only randomly checks quality of care  Pflegegeld is relatively low and insufficient to buy professional care  grey circuit has arisen Employees from new EU member states, who are willing to work for low salaries

21. Grey market in Austria  Providing personal budgets to everyone doesn’t always lead to a market of formal care providers Sweden + Austria: personal budgets  market of individual providers  Austria: recipients not accountable for the way they spend their budget  black market has arisen  Sweden: recipients accountable for the way they spend their budget  black market has not arisen

22. Black care market in Belgium?  Demand > supply home care  waiting lists  Waiting lists + lower prices black circuit workers  potential for black care market  Governmental actions to solve black work in home care sector For example ‘dienstencheques’ (service cheques)  Service cheques  risk that clients don’t receive the services they need Service cheque division vs family care division Familiehulp Price service cheque services < price family care Risk: people in need of family care choose service cheques Client receives wrong services or care Employees confronted with situations they are not prepared and/or educated for

23. The PAB and the black market  PAB users might find it more attractive to hire non- qualified or low-schooled employees  PAB not expected to cause a large black market in Flanders to arise Users accountable for way of spending budget Associations for budget users and PAB advisors  Extension PAB  PGB neither expected to cause a large black market Choice between PAB and PGT or combination PGT: ‘dienstencentrum’ directly receives (part of) budget

24. The PAB and the black market  IT and THAB: recipients not accountable for the way they spend this money Impact on black care market not known