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To be presented at
- Annual Meeting GSA, San Francisco, 16-20 November, 2007
- Presidential symposium, November 18, 2007
Kees Knipscheer - Faculty of Social Sciences /
AOWscope - VU University Amsterdam
(with great acknowledgement to the SHARE and EUROFAMCARE studies:
Börsch-Supon et al, Lamura et al)
From the American point of view Europe may look like a small homogeneous
continent with a very dense population and a luxury Welfare State.
However, talking about Europe is talking about diversity. Europe has an
enormous wealth in its diversity of cultures, histories and policy
approaches. More then any other continent, Europe is blessed with large
cultural, historical and political differences even within small
distances. Comparing countries and regions to simply observe how these
differences have shaped the behaviour of the European citizens is a
fascinating task. In this contribution I will try to show some of these
differences in ageing and family care for the elderly, it is talking
about the European mosaic in long-term care for older people.
A. Historical diversity and common background
Throughout history the Western World has dealt with the problem of
dependent people in many different ways. For centuries, and without
being legally obliged to do so, the family undoubtedly played a crucial
role in caring for dependent older people. However, older people with no
relatives or at odds with their families were left to charitable
associations or taken care of in almshouses. From the 16th century
onwards and especially during the 19th and 20th centuries public
authorities gradually started to play a more significant role. Most such
institutions were set up at a local level by local authorities or
church-related associations. The first relevant national legislation was
introduced in most European countries in the early 19th century. In most
cases the family’s legal responsibility dates back to the 19th century
Napoleontic or Austrian Civil Codes, although some countries (for
instance Hungary) have more recently introduced a specific Family
Responsibility Act. In about half the countries families still have a
statutory responsibility, the law can be enforced through court
decisions ((MESTHENEOS and TRIANTOFILLOU, 2005).
Since the Second World War many Welfare States have taken the lead in
the care of dependent people, and dependent older people in particular.
In other welfare states the primary role in care for dependent older
people (sometimes organised jointly with care for severely disabled
people) is left to the family, volunteer organisations and other support
groups, in some cases with public authority co-financing.
Actually, there is an evident differentiation in formal responsibilities
for dependent older people among the 25 EU Member States. Some countries
argue straightforwardly for state (or municipal) responsibility while
others use historical, legal and/or moral arguments to leave the care of
dependent older people to the family. From the outset the issue appears
to be characterised by a real bi-polarity – primary responsibility lying
either with the public sector or the private sector. Nowadays, the
family’s responsibility for dependent older people has a legal basis in
about two thirds of the 25 EU Member States. In some countries legal
responsibility rests explicitly with the public authorities while in
other countries legal responsibility for care is not explicitly defined
(MESTHENEOS and TRIANTOFILLOU, 2005).
In practice, however, this bi-polarity is much less clear-cut. In
countries where public responsibility is the starting point, a
substantial amount of private care is given, while in countries where
the primary responsibility rests with the private sector, the public
sector has often taken an important role by facilitating and/or
financing private-sector care, and/or supporting carers in the private
sector.
Recent developments and studies also point to a certain rapprochement of
the extremes. In comparison with the first decades after the Second
World War – in the golden days of growing Welfare States – there has in
recent years been less stress on the principle of primary state
responsibility for care for dependent people. The public authorities
have learned to appreciate the contribution of the private sector and
sometimes prefer to restrict their responsibility to dependent people
with the highest level of need. On the other hand, countries that have
left primary responsibility with the private sector appear to be
introducing more and more publicly initiated or publicly supported
contributions, in the form of social insurance schemes, general
assistance regulations and/or support for carers. The issue of
bi-polarity and the public-private mix in long-term care for older
people is a key area of European debate.
B. Common changes in diverse contexts
- demographic changes
EU countries have experienced a number of common changes in the
demographic composition and structure of populations, which have been
more pronounced or have occurred earlier in some countries than in
others. As regards care for dependent older people, the two most
important demographic changes are the extension of life expectancy and
reduced fertility. More people live longer. More people will need
long-term care, while fewer younger people will be available as carers.
Pictures (see pp-presentation)
- family changes
Demographic changes have “verticalised” family structures all over
Europe, with more generations alive at the same time, and fewer people
in the younger generations. As a result of these structural changes
and in a context of increasing industrialisation and mobility, it was
anticipated that the nuclear family would become an isolated unit and
grow apart from other generations. In the 1960s and 1970s, family
sociologists worldwide tried to demonstrate that the nuclear family
was the ideal unit for the industrialised world and that it would
inevitably become isolated from older generations. The traditional
kinship system seemed to be all but dead and a growing generation gap
appeared to be unavoidable. However, over the last 30 years many
studies have demonstrated that by the end of the 20th century the
growing independence of the nuclear family did not destroy the
intergenerational kinship system at all. COLEMAN (1984) demonstrated
repeatedly that older parents are of great value for the majority of
adult children and contribute to a meaningful life. Older parents
appear to refer very often to the relationship with their children as
an enduring source of subjective well-being in later life. In 2000,
ARBER and ATTIAS-DONFUT published an overview of European studies in
“The myth of generational conflict: the family and the state in ageing
societies”. The second chapter reports about the three generation
study by ATTIAS-DONFUT in France. In this study about 2000 men and
women between 49 and 53 were interviewed about their life courses,
their family relationships and about the material and immaterial
exchange between the older, the middle and the younger generation.
Representatives of the older and the younger generations were
interviewed too. One of the major findings, reported here, is that
family transfers are going especially to the neediest family members.
Second, the authors show that the transfers in cash money are mostly
going from the oldest generation to the younger generations (ATTIAS-DONFUT
and WOLFF, 2000). Another chapter on the situation in Norway (GULBRANDSEN
and LANGSETHER, 2000) confirms these findings on cash flow between
generations in France. KOHLI et al. (2000) report about the family
transfers in East and West Germany. Family relationships appear to be
stronger in East Germany than in West Germany, East German retired
people donate more often to their children and relatively also a
higher amount than West Germans. This last finding may be related to
the German public pension scheme, which offers the same amount of
retirement benefits for East and West German retired people. In
another chapter BERNARD et al. (2000), who studied in the nineties
family relationships in London suburbs – selecting the same areas as
WILLMOTT and YOUNG (1960) and YOUNG and WILLMOTT (1957) in the forties
and the fifties - confirmed on the one hand a number of changes since
the sixties, however they also confirmed the actual strength of family
relationships despite a number of disintegrating developments such as
decline in proximity and the loosening of the neighbourhood network.
They conclude that “household size is substantially reduced, more
older people live alone, family networks are smaller in size, the
geographical dispersion of family members is greater, but
intergenerational ties are still strong” (p. 18). LE GALL and MARTIN
(1996) stress that family networks have become more wide spread and
more extensive because of a widening car ownership among parents and
children, the universal use of telephone options, but also because in
many cases of the addition of step-children and step-grandchildren. If
family relationships have become in such a way more separated from
communal networks in the neighbourhood, paradoxically they may have
become more vital family exchange networks.
Based on data from the Dutch Longitudinal Ageing Study Amsterdam (LASA)
a recent cohort comparative analysis by VAN DER PAS, et al (2007)
compared exchange patterns between older parents and their children
among a cohort of parents between 55-65 in 2002 with the same age
cohort from 1992. This study provides evidence of an increase between
cohorts in the exchange of support over the nineties. The late cohort
can be characterized as providing high levels of support and receiving
less than they are giving. In this respect, BENGTSON (2001) notes that
parents are the donors, not the net recipients of cross-generational
support. This also agrees with previous research (BENGTSON and
HAROOTYAN, 1994) showing intergenerational patterns of support flowing
mostly from older generations to younger generations in the family,
which may reflect the intergenerational stake phenomenon (GIARRUSSO,
STALLINGS and BENGTSON, 1995). Moreover, in this respect, we find that
the emotional support given by parents is distinct for the late
cohort. Not only do we find an increase between cohorts in the support
flow downwards but also an increase in emotional closeness.
- changes in norms and values
A specific perspective which can not be left out from this
overview is concerned with the norms and values related to family care
issues. One of the reasons why family sociologists and Welfare State
ideologists in the seventies and eighties of last century where so
pessimistic about future of family relationships was because family
norms and values were on drift. Not only the enforcement of family
obligation was getting more difficult, however there seemed to be a
lot of ambiguity and confusion about the reach of norms itself. Family
rules which had been maintained as legitimate for centuries were
brought into discussion and challenged. KNIPSCHEER (1986) wrote in
these days about the anomy in family care and suggested a kind of
alienation in family care norms. In 1989, FINCH published an in depth
study on family norms in care for older parents. She analysed families
giving a high amount of family care, interviewed family carers about
their motivation and norms and questioned related issues in connection
to the Welfare State. One of her main conclusions was that the norms
about family care “keep sleeping” as long as there is no need for
family care. When the need comes up they have to be negotiated among
the children, and between children and parents, and that the outcome
of this negotiation is not clear from the beginning. Whether and to
what extent family care by children will be given depends to a large
extend from such a negotiation.
A national Dutch study in 2002 asked about 900 family carers about
their motivations to care for by offering them a number of statements.
After analysis these motivations could be reduced to 4 factors. More
than 60 % of the family carers considered the family care giving as a
matter of course, 25 % was giving family acre because the person cared
for preferred to stay at home, 8 % saw no alternative and 5 % cared in
order to keep the relationship good (DUTCH SOCIAL AND CULTURAL
PLANNING OFFICE 2004). On the one hand these outcomes show quite a
high support for family care among family caregivers, however on the
other hand we know from other studies that quite a large proportion of
the population prefers the state to take first responsibility.
Nowadays the retrenchment tendencies in the European Welfare States
will keep the discussion about family and state responsibilities alive.
While the trends are similar throughout Europe, the extent to which
policy-makers are willing – and can afford – to accommodate them
continues to vary greatly.
“Enormous behavioural change in the second half of the 20th century
has resulted in more family breakdown, more fluidity in intimate
relationships, and a large increase in single-person households. In
addition, increasing numbers of women have entered the labour market.
Indeed this has become one point of convergence between EU Member
States”. However, “there has been a shift towards individualisation
that is more evident at the level of prescription than behaviour.
Adults are more economically autonomous and intimate relationships
have become more elective. But care work, which is by definition
relational, is inevitably characterised by interconnectedness, and is
still marked by relations of dependence as well as inter-dependence.
The changing nature of the contributions men and women make to
families requires an effort on the part of policymakers to promote new
forms of social solidarity, both at the level of collective provision
via policies to promote cash payments for care and care services (so-called
de-familialisation), and within the family, by encouraging a more
equal distribution of money and labour between men and women” (LEWIS,
2004, p. 51-52).
The family of the 21st century clearly has two ambitions: to achieve a
more balanced distribution of family care work between men and women
and to share the care responsibility for dependent older people with
public authorities in such a way that family carers can remain
economically independent and socially integrated. These two ambitions
will soon come to the fore in Central European countries as well.
Coming from a regime which pushed most women into employment, women in
these countries may be more accustomed than their counterparts in the
West to sharing care activities. Economic independence seems to be
their main goal.
- changes in the Welfare State
In the first decades after the Second World War, most of the
EU Member States started to develop a modern Welfare State and to deal
with the problem of caring for dependent older people. While most
countries did not do away with families’ legal responsibilities,
public authorities began at the same time to be concerned about the
problem and to introduce home care and institutional care facilities.
On the one hand, these initiatives were entirely in keeping with the
core role of the Welfare State which legitimised its authority by
assuming responsibility for ensuring citizens’ social rights to
education, income, housing and care. On the other hand, public
involvement became essential because of a number of changes in
European societies – demographic shifts, changes in family structures
and in relationships between the generations, and the large-scale
development of professional expertise in many areas (not just among
medical staff, but also among nursing and caring staff and social
workers) – as well as emerging gender and labour-market issues.
Up to the eighties these various Welfare States in Europe evolved
according national traditions, fitting regulations and provisions into
their own national political, economic and social protection systems,
creating comparable provisions as there are special housing and social
care, home care and home nursing, residential care, however implying a
huge diversity in the implementation in the national systems and in
the level of ambitions they were willing and able to afford. At the
same time the EU countries developed the notion of Social Europe and
adopted the European Social Charter (1961) declaring the rights of
older people to full social protection, including support when in need
of long-term care. The renewed Charter of Fundamental Rights of the
European Union (2000) did confirm “The Rights of the Elderly”
explicitly.
Since the nineties long-term care for older people is a topic of
growing importance in the Member States of the European Union and
consequently also within the EU institutions. All the Member States
currently face demographic changes and all need to find ways of
adapting their social systems. The political will exists at Community
level to adapt social systems without renouncing the European social
model. But how is that model – enshrined in Article 2 of the EC Treaty
as the promotion of a high level of employment and of social
protection – to be sustained in the long term? How to keep the EU
Welfare State affordable and sustainable?
In the late 1990s, the Europe of 15 adopted a fresh approach to social
protection which was initially known as the “concerted strategy” and
was later termed the “Open Method of Coordination”. It involved
jointly identifying the challenges at Community level and setting
shared goals with a view to adapting and developing social systems in
a harmonious manner while allowing different national systems to
coexist. The process of convergence has been ongoing since 1997. Since
December 2001, long-term care has been one of the areas covered by the
Open Method of Coordination as applied to health care and care for
older people. The Member States have set themselves a number of shared
objectives to be achieved simultaneously: namely, universal access to
care, a high quality of care and financial viability in care systems.
In the context of the EU efforts to cope with demographic changes and
family developments a number of comparative studies among the EU
member states have been executed in order to understand the
differences and the commonalities between the Sates. Several of them
focussed on the construction of a limited number of prototypes of
Welfare State frameworks, based on the division between public and
private responsibility an/or provision in elder care, on universal or
subsidiary principles in the distribution of elder care, and on tax
paid or social insurance funded elder care. One of the first
frameworks is the one developed by Esping-Anderson in “Three Worlds of
Welfare Capitalism” (Esping-Anderson 1990). Since then both a Southern
European (Ferrera, 1996) and a Central Eastern/Eastern European
framework have been added. The original Esping-Anderson model has been
criticized for focussing on the labour market and ignoring important
gender and family issues (especially important in elderly care). These
issues led to differentiated regime models more focussing on care
regimes in Europe.
Pictures (see pp-presentation)
C. Actual Family Care: continuity and
diversity.
SHARE is the Survey of Health, Ageing and Retirement in Europe,
initiated and greatly financed by the EU Commission and several other
national bodies in Europe. It has gathered data on the individual life
circumstances of about 22.000 citizens aged 50 and over in 11 European
countries, ranging from Scandinavian to the Mediterranean. One of the
key issues in this study was family structure, family networks and
exchanges within the family network.
Research on changes in the family and intergenerational contexts is
“like fighting against windmills: raising empirical arguments against
myths that seem to remain untouched by them. It is widely assumed that
the modern welfare state has undermined family solidarity and the family
itself. Increasing childlessness and fewer births, decreasing marriage
and increasing divorce rates, increasing number of singles and the
decrease of multigenerational co-residence – to name just a few widely
known facts - may indeed indicate a weakening of the family and its
functions. But despite the high intuitive plausibility of such
interpretations in which large parts of the social sciences meet with
common sense, it may turn out that the family has in fact changed but
not diminished its role (cf Künemund and Rein, 1999)” (Kohli, Künemund
and Lüdicke, 2005, p.164)
The following data are taken from the first report of the SHARE study
(report: Health, Ageing and Retirement in Europe, First Results from the
Survey of Health, Ageing and Retirement in Europe, ed. A. Börsch-Supan
et al., 2005, www.straussbuch.net):
Pictures (see pp-presentation)
- Proximity to nearest living child
- Frequency of contact to most contacted child
- Frequency of contact to most contacted parent
- Percentage of grandmothers who looked after their grandchildren at
least weakly and percentage of mothers who are in paid employment (grandmothers
aged < 65)
- Percentage of grandmothers who looked after their grandchildren at
least weakly and percentage of mothers who are in paid employment,
grandmothers aged < 65) Coresidence of older parents and adult
children
- Proprotions of respondents living alone who receive non-family
help with
- Network of people who help with personal care within the household
- Proportions of respondents living alone who receive non-family
help with personal care or practical tasks
- Percentages of respondents who give help
D. Support services for family carers
The frequently mentioned ‘burden’ and spiralling costs for the care of
dependent older people can only be confronted by utilising all available
resources in a partnership approach to care. The policy in the EU to
encourage the labour market participation of women, including older
women, will reduce the already diminishing pool of family carers able to
devote adequate time to hands on care and many ad hoc forms of care
currently utilised to fill this gap may not be the best solutions. The
public sector, already responsible in large part for the health care of
its population, needs to take a proactive role in the allocation of
responsibility and the development of support for family carers.
In the meanwhile national governments in Europe have instituted reforms
that shift the focus of welfare systems from acute to long term care,
with the common policy objective of ageing in place (OECD, 2005).
Recognizing the strategic role of the family and the key role of the
family carers in achieving this aim, some countries have introduced
enhanced carer support initiatives (Kröger, 2003).
With the aim of providing comparative evidence on the availability, use
and acceptability of family care support throughout Europe - a necessary,
preliminary step for the possible development of harmonised directives
and initiatives at EU level - in 2004 the EUROFAMCARE project was funded
by the EU to collect detailed and in depth information on the situation
of carer support in six countries: Germany, Greece, Italy, Poland,
Sweden and the United Kingdom and to complement this with limited
information from all the other EU countries (25 in total, EUROFAMCARE
Consortium, 2006). Due to existing cross-national differences in terms
of family care roles, female employment, public/private mix of care
expenditure and residential/home/monetary share of care provision, the
six core countries represent heterogeneous European care regimes (Alber
& Köhler, 2004; Anttonen & Sipila, 1996; Kautto, 2002; Rostgaard, 2002),
schematically identified as:
- the Scandinavian model (represented by Sweden), characterised by high
public investments in home/residential care and a residual family role,
in connection with high female employment rates;
- the liberal, “means-tested” model (United Kingdom), focussing public
provision of care to the economically more dependent population, thus
implying a broader role for private care providers for remaining users;
- the subsidiarity model (Germany), allocating primary responsibility to
families, backed up however by a long term care insurance scheme funding
care services provided by religious and non governmental organisations;
- the family-based model (Greece and Italy), with limited public
responsibilities and formal service provision, a central role being
played by kinship networks, in connection with low female employment;
- the transition model of post-socialist societies (Poland), resembling
in many aspects that of family-based countries, however with much more
severe financial constraints following recent economic restructuring and
care decentralisation/pluralisation processes (Munday, 2003).
Pictures (see pp-presentation)
- Elder care country clusters
- Over 65 year old people receiving home care (%)
- Over 65 year old people in residential care (%)
- Households with three or more adults (%)
- Provision mix in domestic care
EUROFAMCARE shows the enormous diversity of measures taken to
compensate families for their investment in time and concern (MESTHENEOS
and TRIANTOFILLOU, 2005). Mechanisms include:
· personal budgets, allocated in most cases to dependent people so that
they can employ professional carers or to compensate a family carer or
carers;
· care allowances or care wages, paid either to the person in need or to
the family carer;
· care benefits, paid mostly to the family carer, either in cash or in
the form of tax relief;
· remuneration of care costs;
· payment of a pension to the carer;
· care leave, paid or unpaid, from the work place (normally part-paid in
practice), with varying entitlements in terms of length and frequency of
leave and, in some cases, protection from dismissal;
· respite care, to provide temporary relief for carers.
Pictures (see pp-presentation)
- Support services in 6 EUROFAMCARE countries
Most countries have taken a combination of measures to address the
family care burden. In a number of countries means-testing plays a part.
However, in order to understand the compensatory effect of these
provisions and to evaluate the level of relief afforded, it is crucial
to take into account the amount of money allocated to individuals, the
question of eligibility (depending on the level of need of the person
receiving care) and the proportion of needy older people cared for in
institutions. The latter ranges in the EU countries between 1% and 8% of
over-65s, with institutions normally caring for those most in need (for
instance, in Luxembourg, persons with dementia; see Annex 2). All this
makes comparison between the EU Member States extremely complicated, if
not impossible. Moreover, all these measures can easily be manipulated
to suit national budget considerations at the expense of families
providing care.
Recently, OECD warned policy makers in Europe by saying: “Informal
carers can not be taken for granted as a resource, but require support
in a number of ways, for example, with specialised home-visiting
services and respite care, and help to combine work and caring rather
than leave the labour market on a long-term basis” (OECD 2005).
E. Sustainability of the Welfare State in Elderly Care in EU
countries
The focus of EU policy on the future of the Welfare State, and more
specifically on Elderly Care, is on two issues:
- promotion of participation in the labour force, in combination with
- developing a sustainable elderly care in a cooperation between
informal and formal services and the promotion of support systems for
family carers.
In the late 1990s, the Europe of 15 adopted a fresh approach to
social protection which was initially known as the “concerted strategy”
and was later termed the “Open Method of Coordination”. It involved
jointly identifying the challenges at Community level and setting shared
goals with a view to adapting and developing social systems in a
harmonious manner while allowing different national systems to coexist.
The process of convergence has been ongoing since 1997. Since December
2001, long-term care has been one of the areas covered by the Open
Method of Coordination as applied to health care and care for older
people. The Member States have set themselves a number of shared
objectives to be achieved simultaneously, namely:
- universal access to care,
- a high quality of care and
- financial viability in care systems.
The European Commission set out an initial general framework to
guarantee accessibility, quality and financial viability in its
Communication on the future of health care and care for the elderly
(December 2001, March 2003) and in the open method of coordination on
health care and long-term care for the elderly (April and October 2004).
Long-term care services should be made available at the place where and
time at which they are needed, and should meet the specific needs of the
client at a cost the client can afford. To achieve this goal, public
institutions in some countries pay cash benefits and leave recipients to
choose the services that they need. In other countries, recipients can
make their own arrangements to meet recognised needs and pay the
provider’s bill, thereby avoiding misuse of resources by irresponsible
recipients. It has often been pointed out in the debate surrounding this
issue that practices of this kind are in keeping with the principle of
personalisation, but should not relieve the public authorities of their
responsibility to make the necessary services available at the place and
time that they are needed.
Providing an infrastructure for long-term care services can actually be
managed in two completely different ways: as a state responsibility or
as a market supply and demand system. If the state takes full
responsibility, it removes an economic sector, i.e. the long-term care
sector, from the market, and plans a supply of long-term care services
which are sufficient in number, available in a timely way and of
adequate quality. The market system has different rules: demand and
profitability play a part in the provision of long-term care services. A
market system may not in practice provide enough long-term care services
which are available in a timely way and of adequate quality.
These two fundamentally different solutions are in practice being
supplemented by a myriad of transitional solutions. The state can, for
instance, assume its responsibilities by surveying what is available in
the market and, after pinpointing potential shortcomings in the supply
of care services, become a promoter of services or a service provider
itself. If the state promotes services by awarding aids, it may well be
that European regulations prohibit such aids (see Article 87 of the
Treaty). The issue in this case is whether the services provided by the
state can be deemed to be “services of general economic interest” (Article
16 of the Treaty).
If the state is responsible for the provision of long-term care
infrastructure, a further question is the level at which the state
should organise it: the central/national level, the regional level or
the municipal level? This tends to be shaped by the way in which each
Member State organises its administration, which is a constitutional
matter for each state.
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