1. 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

2. 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

3. 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

4. The ’ups and downs’ of Swedish eldercare Coverage: back to mid 60s – but still more generous than in most countries

5. 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’

6. 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?

7. 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

8. Eurobarometer survey 2007 Is family care or formal care the best option for an elderly parent?

9. Strong correlation between view on care workers and willingness to use services Eurobarometer 2008

10. Why do Swedish people prefer formal, tax- funded care to family care or market services? What is home care in Sweden? What is residential care? Has the universal ‘caring state’ a future?

11. 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

12. 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

13. 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

14. A Swedish nursing home today

16. A Swedish nursing home in 1975

17. 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 From health care to social care; from patient to tenant

18. 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

19. 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

20. Huge variation in employment rates of middle aged women % of women 55-64 years old in paid employment, 2007 ( Eurostat)

21. 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

22. 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

23. The more resources for long-term care  the more middle-aged women in paid work

24. 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.

25. 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.