Long term care policies for older people in
Sweden: are there lessons to learn?
April 16, 2013
Scottish Parliament
Seminar organised By Nordic Horizons
Marta Szebehely
Professor of Social Work
Stockholm University
marta.szebehely@socarb.su.se
Point of departure
• Care services part of social infrastructure
• Care policies deal with risks related to needing
as well as giving care – affect the welfare of
three parties:
– persons in need of care
– their families “working mothers and working
daughters” (Anttonen)
– paid care workers
• Eldercare is not just an expense – also a
facilitator of middle-aged children’s
employment
The Nordic universal ‘caring state’
as an idea(l)
•
•
•
•
•
•
Generous provision of publicly financed high
quality services – no means-testing
Mainly publicly provided
Directed to and used by all social groups
Accessible, affordable (also for the poor) and
attractive (also for middle class)
Universal and individualised
Highly independent local state (municipalities)
collect taxes and organise the services
The ’ups and downs’ of Swedish eldercare
Proportion (%) of pop. 80 years+
70
60
50
34
25
40
Receiving home
care
26
30
18
23
10
20
28
10
Living in
residential care
28
22
20
20
14
0
1960
1970
1980
1990
2000
2012
Coverage: back to mid 60s – but still more generous than in most countries
Consequences of declining public services
– an issue of equality: gender and class
•
Increase of help from family among elderly with
fewer resources (Informalisation)
•
Increase of privately purchased services among
elderly with more resources (Privatisation)
•
Increase of help by daughters rather than sons:
affects the lives of ‘working daughters’
Marketisation of Swedish tax-funded eldercare
• Private provision of tax-funded eldercare
– 2% 1993; 21 % 2012 – entire increase in for profit
• Hugh variation within country
– No private homecare providers >1/2 of municipalities
– Stockholm: 73% of nursing homes and 61% of homecare hours are
provided by for-profit providers (100 companies in each area)
• Fragmented but also highly concentrated market:
increasingly owned by international private equity
• Sweden a paradise for care capital: generous funding,
tradition of trust – very little regulation and control
• Will recent scandals change the picture?
What kind of care do older people in
Sweden prefer? (year 2000)
•
Older people (75+) living at home who need
help with bathing or toileting:
–
–
–
–
•
•
60 % prefer public home-care services
10 % prefer help from daughter or other relative
27 % prefer help from a spouse
<1 % prefer help from market or voluntary org.
No class difference in preferences for family
care
But older people with longer education are
more interested in market help
Is family care or formal care the best option for
an elderly parent?
Sweden
Denmark
Netherlands
Finland
France
UK
Germany
Greece
0
10
Live with child
20
30
40
50
Child visit and help
60
70
80
90
Home care or nursing home
Eurobarometer survey 2007
100
Strong correlation between view on care workers and
willingness to use services
40
DK
Agree totally that
care staff are doing 35
an excellent job (%) 30
SE
FI
MT
25
NL
DE
20
BE
AT
LV
LU
CZ
15
R2 = 0,68
FR
UK
IE
HU
10
PT
LT ES
5
PL
EL
CY
RO BG
0
0
EE
SI
SK
10
20
30
IT
40
50
60
70
80
90
Prefer services rather than family care for a dependent parent (%)
Eurobarometer 2008
Why do Swedish people prefer formal, taxfunded care to family care or market services?
• What is home care in Sweden?
• What is residential care?
• Has the universal ‘caring state’ a future?
Public home-care services
an important part of the emerging universal welfare
state – and a ‘Freedom-of-choice’-revolution
• Started around 1950 - the first social service aimed at
and used by all social groups
• Made it possible for frail older persons to stay at home
without being dependent on their children
• Made it possible for middle-aged daughters to be
gainfully employed
• Universal pensions and improved housing were crucial
What is home care in Sweden today?
• Household tasks, personal care, social support + help
with medication + rehabilitation
• ¾ of workers have some formal training
• Covers 9% of 65+ (decrease from 18% in 1980)
• 7 hours/week on average but intensity varies from
once a month to several times a day and night
• Less individualised but still appreciated and used by
all social groups
Swedish residential care of today
• Covers 5% of 65+ (shrinking)
• 80% of residents are 80+, 2/3 suffer from cognitive
impairment/dementia
• Single room/apartment with private furniture (98%)
• Private bathroom (>90%)
• Private cooking possibilities (>70%)
• Usually 8-10 rooms in a unit sharing a combined
kitchen/living-room
A Swedish nursing home today
A Swedish nursing home in 1975
From health care to social care;
from patient to tenant
• Turning point: Community care reform in
1992 (Ädel): nursing homes shifted from
health care (21 county councils) to social
care (290 municipalities)
• Today: same legislation (Social Services Act)
regulates all form of care: home care, service
housing, old-age homes and nursing homes
Rent, meals and care paid separately
– same system in residential and home-based care
•
Rent: in principle same as at home, but often higher
(£450-900/month); low income pensioners get state
financed housing allowance (up to £510/month)
•
Meals: per meal (in service housing or at home) or full
board (average £300/month)
•
Care: related to income (but not assets), max
£175/month – same at home and in residential care; low
income pensioners are exempted from fees
•
No (strong) financial incentives to refrain from or
choose residential care
Sweden a generous spender – can we
afford the universal model in the future?
• Arguments against:
– Demographic ageing
– Rising top incomes  increasing demands
• Arguments for:
– Sweden less affected by demographic ageing thanks
to high birthrates (childcare services crucial)
– No class differences in user satisfaction with
eldercare services
– Voters’ willingness to pay tax for welfare services, in
particular eldercare
– Eldercare not only an expense
Huge variation in employment rates of
middle aged women
80
70
60
50
40
36,0
30
20
% of women 55-64 years old in paid employment, 2007 (Eurostat)
MT
PL
SK
SI
IT
BE
HU
EL
AT
LU
ES
CZ
RO
BG
EU27
FR
IE
NL
CY
DE
PT
LT
UK
LV
DK
FI
EE
0
SE
10
Differences between groups of women
% of women 55-59 years old in paid employment, 2005:
• Women with high education in EU-25: 70%
– 60%+ in 18 of 25 countries
• Women with low education in EU-25: 36%
– 60%+ in 2 of 25 countries (DK, SE) (+ Iceland)
Eurostat
Why do less educated middle-aged women in
Scandinavia have relatively high employment rates?
• Eldercare services: also accessible for less
well-off groups
• Facilitate the combination of caring
responsibilities and paid employment also for
those with less resources
• Care services: a large labour market also for
less educated women
The more resources for long-term care  the
more middle-aged women in paid work
80
SE
Employment rate, women 55-64 years
70
60
FI
50
UK
PT
40
IE
CZ
LU
HU EL
20
DK
DE
NL
ES
30
R² = 0.54
FR
AT
IT
BE
PL
10
0
0
0.5
1
1.5
2
2.5
Public resources for LTC as % of GDP
3
3.5
The universal model at the cross roads:
it can survive…
• If middle-class older people continue to find the public
services attractive enough
• If the services are not under-funded
• If political leadership listens to the grassroot voters
willing to pay more tax
• If the strong market actors don’t push politicians further
towards a dualised care system with basic services and
family care for those with fewer resources and high
quality ’topped-up’ services for those who can afford it.
Further reading
Szebehely M & Trydegård G-B (2012) Home care in Sweden: a
Universal Model in Transition, Health & Social Care in the
Community, 20 (3) (special issue on home care in Europe)
Szebehely M (2009) Are there lessons to learn from Sweden?
In: Armstrong P et al eds. Designing Gender-Sensitive
Long-Term Care in Canada. Toronto: Fernwood Books.
Meagher G & Szebehely M (2013) Long-term care in Sweden:
Trends, actors and consequences. In: Ranci C & Pavolini E,
eds. Reforms in long term care policies in Europe:
Investigating institutional change and social impacts, New
York: Springer
Vabø M & Szebehely M (2012) A caring state for all older
people? In: Anttonen A, Häikiö L & Stefánsson K, eds.
Welfare State, Universalism and Diversity. Cheltenham:
Edward Elgar.