Care Work in the EU: Support Measures in a Context of Demographic Change

4. Policy Developments in Member States

In practice the main responsibility and resources for implementing policies on care apply mainly at the level of the EU’s Member States. These 27 countries have developed services and supports largely in their own cultural, economic, demographic and political contexts, with huge variety and diversity of approaches to supporting care work. Österle and Meichenitsch (2006) argue that among countries in Southern and Eastern Europe it is only recently that some have put forward proposals for policies on long-term care, or that they have only begun to develop such proposals or to implement schemes. Available data on long-term care expenditure give only a general impression but this is of marked differences between countries in spending, ranging from less than 0.5% to more than 2.5% as a proportion of GDP.

In some countries in Central and Eastern Europe, there is a tradition of paying allowances to informal carers. Such payments directed at informal carers still exist in Hungary and Slovakia. In Hungary, for example, the level of the benefit is oriented at the minimum pension, with the opportunity to lower or to extend the benefit depending on the status of the person in need of care. The period in which the benefit is paid is also recognised as a contribution period in pension insurance. In the Czech Republic a care allowance scheme was introduced in 2006, alongside new laws on accreditation of social services. Recent reform debates in Central and South Eastern Europe stress quite similar objectives: decentralisation; clarification of responsibilities for funding and provision of health and social care; diversificiation of service provision; the development of infrastructure for social services in the community; and the improvement of access and efficiency. However there is a lack of both public debate on the development of such support services as well as financial resources.

A range of models for the provision of care is also evident in Western European countries on a spectrum from approaches which are strongly based on family and informal care (e.g. Italy) to those driven by development of formal services (e.g. Sweden, the Netherlands). However, Pavolini and Ranci (2008) looked at developments in six Western European countries and identify a common trend for new policies – to rethink the relationship between family care and formal services, so that formal and informal services are no longer considered as mutually exclusive but as complementary activities. This is reflected in the growth of public initiatives to support and supplement family care by: targeting of cash benefits to support informal caregivers; greater flexibility in the packaging of care services; increased choice for service users; and measures to reconcile caring with paid employment. At the same time the supply of home care services has been diversified and increased by introducing competition into public sector systems and incentives to develop private services.

There has been some criticism that cash measures ostensibly to support informal caregiving have, in practice, trapped women in poorly rewarded care work and restricted their opportunities in the labour market — while saving the funds of public health and welfare programmes. Pavolini and Ranci (2008) argue, however, that the new policies actively recognise and sustain family caregiving, making it an explicit and not taken-for-granted resource. These measures for family carers include: social security contributions; provision of training courses; accident and health insurance and the availability of respite services.

5. Family Care: Practices and Preferences

Eurobarometer surveys of the general population have been used to ask a series of questions about care, who provides it and preferences regarding care provision. They reveal a remarkably high level of family or informal caregiving throughout Europe (Alber and Kohler, 2004). In the most recent, 2007, survey (Eurobarometer, 2007) more than one in three people reported involvement with someone who, over the previous ten years, had been in need of regular help and long-term care. The largest segment of respondents indicated that one of their parents (15%) or another relative or friend (13%) had needed care; perhaps surprisingly only 4% reported providing care to their partner (which may reflect how people understand the question). Women were somewhat more likely than men to report being personally involved in providing care, but the main socio-demographic difference was in relation to age: 30% of people aged 55-64 reported having an elderly parent who had needed long-term care over the previous ten years.

Looking at individual countries there were no clear distinctions between exposure to long-term care needs in the old and new Member States: the reported experience of care was lowest in Romania and Portugal, but highest in Sweden and Denmark — so there are no clear signs that the expansion of services in the EU15 (the older Member States of Western Europe) has eroded family care.

Among the respondents who have someone they are close to who is, or was, in need of regular help and long-term care, most are personally involved in helping this person. Nearly half of these “informal carers” indicate that they regularly visit or visited the person to keep them company (49%) and more than four out of ten help with shopping (42%). Other often cited ways of helping are cleaning (34%), helping with mobility (33%), cooking (32%) and taking care of finances and everyday administrative tasks (30%).

Table 1: Meeting care needs
QA11 Thinking about this case of long-term care need you have just told me about, please tell me in what ways, if any, do you or did you personally get involved in helping this person (Multiple answers possible) – % EU27 (Eurobarometer, 2007)

Overall, women are clearly more often fully involved in informal care than men. Nearly a half of female carers shop for the person they are helping compared to just over a third of men. Women are twice as likely to cook and far more likely to clean, help with dressing, help with bathing and showering, help with feeding, and help with using the toilet.

Table 2: Where caring takes place
BASE: Those who are informal carers who help someone they are close to.
QA12 Still thinking about this particular case of long-term care need you have just told me about, where did this person live for the longest time during this period in which he or she needed care? — EU27 (Eurobarometer, 2007).

Regular help and long-term care is most often provided to a person who lives in the household of the carer (37%). Rarely do people provide care to a person that lives more than 20 kilometres away (12%). Fourteen% of respondents reported providing care to a person living in a nursing home. In a 2002 Eurobarometer survey care given to a person not living in the person’s household was found to be more common in the EU15 countries, while carers in the new Member States were more likely to be caring for direct family members. Alber and Kohler (2004) argue that the scale of family care in the new Member States is not merely a response to a lack of public services but an indicator of the strength of adhesion to family values. Similarly, they propose that the distribution of care activities in the EU15 countries contradicts the idea that informal care and publicly provided community care are opposites or replace each other. In the EU15 informal care outside the home is most frequent in those countries such as Sweden and Denmark where formal community services are most developed.

Turning to expectations and preferences for long-term care the recent Eurobarometer underlines the preference for home care albeit with growing involvement of paid carers. As Table 3 shows 45% of people expect and prefer to be looked after in their own home by a close relative. In fact, expectations and preference are fairly evenly matched for all forms of care. Around a quarter of Europeans expect and prefer to be looked after in their own home by a professional care service (23% and 24% respectively) and around one European in ten expects and prefers to be looked after in their own home by a personal carer (10% and 12% respectively). Just under one in ten Europeans say they expect and prefer to be looked after in a long-term care institution (9% and 8% respectively) and around 5% expect and prefer to be looked after in the home of a close family member.

Table 3: Expected and preferred way of getting assistance if one becomes dependent and needs regular help and long-term care – % EU27
Source: (Eurobarometer, 2007).

People’s expectations and preferences depend to a degree on their family situation. Those with children or an elderly parent living at home are slightly more inclined to think that they will be looked after in their own home by a family member if they need help in the future.

National norms and values — and the current availability of services — produce the largest differences in opinions. The expectation to be looked after by a relative at home ranges from 22% in Denmark to 75% in Turkey while the preference to be looked after this way is also lowest in Denmark (20%) but highest in Central and Eastern European countries such as Hungary (66%) and Poland (70%). The expectation to be looked after in one’s own home by a professional care service ranges from 4% in Croatia to 51% in Denmark while the wish to be looked after in this way is lowest in Hungary and highest in Denmark.

When asked about the best option for an elderly parent living alone who can no longer manage without regular help, three out of ten Europeans believe the best option is to live with their children. However, as Table 4 shows, there are many European who believe elderly parents should stay at home and receive regular care visits either from a public or private care service provider (27%) or from their own children (24%). In fact, being looked after by a child at home is the second best option according to 34% of Europeans. Nursing homes are not often viewed as a preferable option, and this is the case in nearly all Member States.

Table 4: Best option for an elderly parent living alone and in need of regular help First and Second option – % EU27
Source: (Eurobarometer, 2007).

Views about the best option for elderly parents who can no longer live alone vary strongly from country to country partly as a result of cultural differences in traditional kinship relationships in Europe. Consequently, in Turkey nearly three out of four respondents believe the best option is that the elderly parent lives with a child (74%). Conversely, less than one person in ten in Sweden and the Netherlands (both 4%), Denmark and Finland (both 7%) shares this view and in these countries more than half of the public feels that public or private service providers should be hired to take care of elderly parents in their home.

To better understand how people think long-term care should be supported the Special Eurobarometer (2007) asked about agreement with a series of statements. The European public broadly supports the idea that public authorities should provide appropriate home care and/or institutional care for elderly people in need, with 93% of European citizens agreeing. There is also widespread agreement with the notion that family carers should receive (financial) support from the state: 91% of respondents feel they should be given a chance to take a break and 89% feel they should be paid an income for their duties if they give up working or have to reduce their working hours. The majority of Europeans (70%) feel that payment should be obligatory into an insurance scheme that will finance care if and when it is needed.

Table 5: Responsibilities for care of elderly

QA8 For each of the following statements regarding the care of the elderly, please tell me to what extent you agree or disagree? – % EU27 (Eurobarometer, 2007)

The argument that public authorities should be involved in providing care is endorsed by more than nine out of ten people in all Member States, except Italy (88%) and Hungary (85%). There is also a widespread consensus that the state should pay for professional carers to give respite to family carers. Support for the view that the state should pay an income to those who have to give up working or reduce their working time to care for a dependent person ranges from 77% in Luxembourg to 94% in Greece, Spain, the Czech Republic and Malta.

National views are more diverse when it comes to the idea of contributing to an insurance scheme to finance care if and when it is needed. Support for this notion is most widespread in Luxembourg (86%), Belgium, Greece (both 85%), Germany and the Netherlands (both 83%) and least widespread in Finland (41%) and Denmark (42%). This reflects the current situation with long-term care insurance schemes operating in countries such as Luxembourg, Germany and the Netherlands, while the Scandinavian countries have universal tax-based social protection. Support for the notion that close relatives should care for dependent people even if that means that they have to sacrifice their careers to some extent ranges from only 7% in Sweden to 77% in Turkey; the figure is generally higher in the new Member States of Central and Eastern Europe.

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