1. Family, Gender and the Welfare State, Oxford Institute of Social Policy, 26 January 2012 The Provision of Family Care for Older People in Europe The Role of Long-term Care Systems Linda Pickard, Senior Research Fellow Personal Social Services Research Unit London School of Economics & Political Science

2. The Provision of Family Care for Older People in Europe: The Role of Long-term Care Systems Family care is very important in care of older people in Europe Long-term care systems in Europe vary considerably in their reliance on family care (Haberkern & Szydlik 2010) Are differences in long-term care systems associated with differences in provision of informal family care? Pickard L (2011) The Supply of Informal Care in Europe. ENEPRI Research Report No. 94. Centre for European Policy Studies (CEPS) http://www.ceps.eu/book/supply-informal-care-europe

3. The Provision of Family Care for Older People in Europe: The Role of Long-term Care Systems Relevant to family, gender and welfare state Most family care for older people in Europe is provided by women (EC 2007) Provision of unpaid family care to people with disabilities and older people has negative effect on paid employment (Spiess & Schneider 2003, Lilly et al 2007, Carmichael et al 2010, Heitmueller 2010) Long-term care systems that are associated with reduced provision of unpaid family care could promote gender equality (Himmelweit and Land 2008)

4. Background: the ‘ANCIEN’ study Research is part of Assessing Needs of Care in European Nations (ANCIEN) study ANCIEN is concerned with the future of long-term care for older people in Europe ANCIEN is funded by 7 th EU Research Framework Programme, from January 2009 to August 2012 20 partners from EU member states Workpackage (WP) structure of ANCIEN WP1 typology of long-term care systems (Kraus et al 2011) WP3 analysis of informal care provision (supply)

5. ANCIEN typology of long-term care systems Clusters and representative countries ClusterCountriesKey characteristics Cluster 1Belgium, Czech Republic, Estonia, Germany, Slovakia low public expenditure low private expenditure high informal (family) care use Cluster 2Denmark, The Netherlands Sweden high public expenditure low private expenditure low informal (family) care use Cluster 3Spain, France, Finland, Austria, Slovenia, UK medium public expenditure high private expenditure high informal (family) care use Cluster 4Hungary, Italy, Polandlow public expenditure high private expenditure high informal (family) care use

6. Key features of ANCIEN typology of long-term care systems Key difference with regard to reliance on informal care is between Cluster 2 and other countries Cluster 2 (The Netherlands) has low use of informal care, whereas all other clusters have high use of informal care Cluster 2 also has high public expenditure on long- term care, whereas all other clusters have medium to low public expenditure on long-term care. Cluster 2 countries characterised as “generous, accessible and formalised” long-term care systems (Kraus et al 2011)

7. Typology generates research questions Typology is based partly on extent to which long-term care system relies on informal family care International literature suggests that reduced reliance on informal care in long-term care system does not necessarily lead to reduced provision of family care ‘Substitution’ hypothesis: strong welfare state leads to reduction in provision of informal care (Lingsom 1997) ‘Complementarity’ hypothesis: strong welfare state encourages families to continue/increase informal support (Motel-Klingebiel et al 2005; Haberkern & Szydlik 2010) Key question: Is provision of informal family care lower in countries with “generous, accessible and formalised” long- tern care systems (Cluster 2) than other countries?

8. The Provision of Family Care for Older People in Europe: The Role of Long-term Care Systems Outline Objective is to analyse provision of informal care across Europe by clusters and representative countries, controlling for key factors 1.Methods 2.Results: variations in informal care provision controlling for key socio-demographic variables 3.Results: impact of need for long-term care on informal care provision 4.Conclusions: role of long-term care systems in provision of family care in Europe

9. (1)Methods: data sources Key issue in analysis of supply of informal care in Europe is availability of comparative data Various data sources considered European Community Household Panel (ECHP) Survey of Health, Ageing and Retirement in Europe (SHARE) Current analysis uses Eurobarometer 67.3 data Eurobarometer survey includes recent information on informal care provision and potentially associated variables in all countries in ANCIEN study

10. Eurobarometer data on informal care Eurobarometer 67.3 is survey commissioned by Directorate-General for Employment, Social Affairs and Equal Opportunities of European Commission Examines public opinion about health care across Europe, focusing specifically on long-term care and care of elderly Between 25 May and 30 June 2007, 28,660 Europeans aged 15 and over interviewed Survey covers 27 European Union Member States and 2 candidate countries (Croatia and Turkey) Approximately 1,000 people in each country interviewed

11. Eurobarometer data on informal care Eurobarometer 67.3 includes question on provision of informal care Respondents are asked if they, or someone they are close to, has “ever been in need of any regular help and long-term care over the last ten years” If so, they are asked to identify their relationship(s) to up to two people (e.g. partner, parents, other relatives) Respondents are identified as potential “informal carers” if they identify someone who has, or has had, a long-term care need and person involved is or was a partner, parent, child, sibling, another relative, friend, acquaintance, colleague or neighbour

12. Eurobarometer data on informal care Potential informal carers are then asked “do you or did you personally get involved in helping this person” Possible responses (with multiple answers possible) include –“you are/were not personally involved in helping this person” –visiting regularly to keep company –cooking and preparing meals –doing shopping –cleaning and household maintenance –taking care of finances and everyday administrative tasks –help with feeding –help with dressing –help with using the toilet –help in bathing or showering –organising professional care

13. Eurobarometer data on informal care In addition, Eurobarometer includes variables potentially associated with informal care provision, e.g. age, gender, marital status, education Survey also includes other questions relevant to informal care provision e.g. long-term care need Initial investigation into Eurobarometer data Comparison of probability of providing informal care using Eurobarometer and national survey data in one ANCIEN country (UK) Eurobarometer - 33% of sample in UK provides or provided informal care (2007) British Household Panel Survey (BHPS) (2007) - 17% of sample provides informal care

14. Eurobarometer data on informal care Prevalence of informal care provision higher in Eurobarometer than BHPS BHPS asks about present provision of informal care, Eurobarometer asks about provision of informal care over last 10 years Eurobarometer includes past carers Past experience of informal care is important since provision of informal care can affect employment/health beyond period during which care provided Eurobarometer measure of informal care acceptable in comparative analysis of informal care, but definition should be kept in mind

15. Methods: sample sizes Re-analysis of 2007 Eurobarometer data on informal care Weighted sample size of EU27 countries: 26,659 Sample size of ANCIEN countries: 25,224 Sample size of ANCIEN clusters: 23,252 Sample size of ANCIEN representative countries: 9,931 –Cluster 1: 5,888 (Germany: 4,367) –Cluster 2: 1,691(The Netherlands: 884) –Cluster 3: 9,610(Spain: 2,512) –Cluster 4: 6,063 (Poland: 2,169)

16. Methods: measures of informal care Weighted sample numbers providing informal care expressed as per cent of total weighted sample base (excluding missing data) Focus on provision of help with Activities of Daily Living (ADLs) or personal care tasks Defined as help with four ADLs: feeding, dressing, using toilet, bathing/showering Reasons for focus on help with personal care Two measures of informal help with ADLs –informal help with one or more ADLs –informal help with two or more ADLs

17. Methods: factors taken into account Bivariate and multivariate analysis of informal care provision Includes 4 key socio-demographic factors: gender, age, marital status, education –Age-bands: 15-29; 30-44; 45-64; 65 and over –De facto marital status: married/cohabiting and single (non-married/non-cohabiting) –Education: ending education at ages 15 ; 16-19 and 20 or older Also includes long-term care systems measured by typology of clusters and representative countries

18. (2) Results: bivariate analysis of informal care provision in Europe Bivariate analyses examine variations in provision of help with one or more ADLs & two or more ADLs by –clusters –representative countries Variations by key socio-demographic variables are then added to the analysis Is provision of informal care lower in Cluster 2 countries than other countries?

19. Informal help with one or more ADLs in Europe by ANCIEN country

20. Informal help with two or more ADLs in Europe by ANCIEN country

21. Informal help with ADLs by ANCIEN cluster

22. Informal help with ADLs by ANCIEN representative country

23. Informal help with two or more ADLs by ANCIEN representative country and gender

24. Informal help with two or more ADLs by ANCIEN representative country and age

25. Informal help with two or more ADLs by ANCIEN representative country and de facto marital status

26. Informal help with two or more ADLs by ANCIEN representative country and education (terminal age of education)

27. Results: multivariate analysis of informal care provision in Europe Examines factors associated with provision of informal help with 1 or more and 2 or more ADLs in Europe Logistic regression models include key socio- demographic factors and clusters or representative countries 1.Provision of help with one or more ADLs + clusters 2.Provision of help with one or more ADLs + countries 3.Provision of help with two or more ADLs + clusters 4.Provision of help with two or more ADLs + countries Do differences between clusters and representative countries remain when socio- demographic factors are taken into account?

28. (1) Logistic regression model of proportion of population aged 15+ providing help with one+ ADLs, clusters VariableCategoriesOdds ratios, significance GenderMen1.00 Women***1.83 Age15-291.00 30-44***1.41 45-64***2.55 65+***2.43 De facto marital statusMarried or cohabiting1.00 Not married or cohabiting(ns) 1.00 Terminal age of education151.00 16-19***0.83 20+ (ns) 0.98 ClustersCluster 21.00 Cluster 1**1.28 Cluster 3***1.28 Cluster 4***1.38

29. (2) Logistic regression model of proportion of population aged 15+ providing help with one+ ADLs, representative countries VariableCategoriesOdds ratios, significance GenderMen1.00 Women***1.84 Age15-291.00 30-44***1.49 45-64***2.87 65+***2.63 De facto marital statusMarried or cohabiting1.00 Not married or cohabiting(ns) 1.06 Terminal age of education151.00 16-19***0.78 20+ (ns)1.01 Representative countriesThe Netherlands1.00 Germany (ns)1.19 Spain**1.56 Poland***1.61

30. Summary of results of multivariate analysis of provision of help with one or more ADLs Controlling for gender, age, marital status and education provision of informal help with 1 or more ADLs is significantly higher in Clusters 1, 3 and 4 than Cluster 2 provision of informal help with 1 or more ADLs is significantly higher in Spain and Poland than The Netherlands provision of informal care with 1 or more ADLs is higher in Germany than The Netherlands but difference is not statistically significant

31. (3) Logistic regression model of proportion of population aged 15+ providing help with two+ ADLs, clusters VariableCategoriesOdds ratios, significance GenderMen1.00 Women***2.00 Age15-291.00 30-44***1.64 45-64***2.76 65+***2.66 De facto marital statusMarried or cohabiting1.00 Not married or cohabiting(ns) 1.05 Terminal age of education151.00 16-19***0.83 20+ (ns) 0.89 ClustersCluster 21.00 Cluster 1***1.62 Cluster 3***1.56 Cluster 4***1.79

32. (4) Logistic regression model of proportion of population aged 15+ providing help with two+ ADLs, representative countries VariableCategoriesOdds ratios, significance GenderMen1.00 Women***2.10 Age15-291.00 30-44***1.65 45-64***3.05 65+***2.96 De facto marital statusMarried or cohabiting1.00 Not married or cohabiting(ns) 1.12 Terminal age of education151.00 16-19***0.83 20+ (ns) 0.97 ClustersThe Netherlands1.00 Germany**1.51 Spain***1.95 Poland***2.20

33. Summary of results of multivariate analysis of provision of help with 2 or more ADLs Controlling for gender, age, marital status and education provision of informal help with 2 or more ADLs is significantly higher in Clusters 1, 3 and 4 than Cluster 2 provision of informal help with 2 or more ADLs is significantly higher in Germany, Spain and Poland than The Netherlands

34. Results of multivariate analysis of provision of informal care in Europe: summary Controlling for key socio-demographic factors, there are significant differences in informal care provision between countries with different long-term care systems Informal care provision is affected, not only by differences in socio-demographic factors, but also by differences in long-term care systems Implications for substitution and complementarity hypotheses examined in conclusions

35. (3) Impact of need for long-term care on informal care provision: methods Differences in informal care provision may be due to differences in need for long-term care Is informal care provision in Cluster 2 countries lower because need for long-term care is lower? Examined by looking at variations in disability rates between clusters and representative countries Eurobarometer asks about functional disability Analysis here focuses on “significant difficulty” with ADLs (feeding, dressing, using toilet, bathing/showering) Focuses on disability rates in household population aged 15+ (excluding missing data), using bivariate analysis

36. Household population aged 15 and over with difficulty carrying out ADLs: ANCIEN cluster

37. Household population aged 15 and over with difficulty carrying out ADLs: ANCIEN representative country

38. Impact of need for long-term care on informal care provision: summary Proportion of household population with long-term care needs seems higher in Cluster 2 countries (The Netherlands) than elsewhere Reason why informal help with personal care tasks is lower in Cluster 2 countries and the Netherlands does not appear to be because need for long-term care is lower However, there are limitations to analysis, discussed in conclusions

39. (4) Summary & Conclusions Role of long-term care systems in provision of family care in Europe Is provision of informal family care lower in countries with “generous, accessible and formalised” long- term care systems than other countries in Europe? Countries characterised as having “generous, accessible and formalised” long-term care systems in ANCIEN study are Denmark, The Netherlands and Sweden (Cluster 2 countries) Based on analysis of 20 European countries, Cluster 2 countries have amongst lowest provision of informal help with one or more personal care tasks in Europe

40. Conclusions (continued) Cluster 2 countries have lowest provision of informal help with 2 or more personal care tasks in Europe Differences between countries are particularly marked where most demanding informal care is concerned, that is, help with 2 or more personal care tasks Controlling for key socio-demographic factors, ANCIEN Cluster 2 countries are characterised by lower provision of informal help with 2 or more personal care tasks than other European countries

41. Conclusions (continued) Controlling for key socio-demographic factors, the country representing Cluster 2, The Netherlands, is characterised by lower provision of informal help with 2 or more personal care tasks than countries representing other clusters, i.e. Germany, Spain and Poland Reason why informal help with personal care tasks is lower in Cluster 2 countries/The Netherlands does not appear to be because need for long-term care is lower

42. Conclusions (continued) Limitations –informal care definition includes past as well as present provision of care –analysis of need looks at household population only Some limitations addressed in further ANCIEN analysis Using SHARE data to look at informal care provision for older people by population aged 50 and over Past caring not so much an issue in SHARE SHARE analysis confirms results shown here Provision of personal care to older people is lower in The Netherlands than in any other ANCIEN representative country

43. Conclusions (continued) Evidence supports ‘substitution’ hypothesis that ‘strong welfare state’ leads to reduction in provision of informal care Little support for ‘complementarity’ hypothesis that ‘strong welfare state’ encourages families to continue/increase informal support Introduction of more generous, accessible and formalised long-term care systems could promote gender equality by reducing informal care provision and enhancing women’s opportunities to take up paid employment

44. The Provision of Family Care for Older People in Europe: The Role of Long-term Care Systems Thank you for your attention L.M.Pickard@lse.ac.uk