Ageing, families and welfare systems: Comparative perspectives

Some convergence between countries may be observed in total welfare spending during the later decades, but while levels are becoming more similar, the profiles are still very different. Some welfare states are high on transfers, others on services, and among services – some give priority to institutions, others invest more heavily in community (home) care. Discussed in this article is how different family cultures are reflected in welfare systems, and conversely – how welfare systems in turn may influence families. The article argues that home care services tend to have lower priority in countries with familistic policies, and higher priority where social policies are individualistic. What model is the more sustainable for the future, given the social and demographic changes to be expected?     

Changing policies, changing patterns of care: Danish and Swedish home care at the crossroads

Despite pursuing the policy of ageing in place, the two Nordic countries of Denmark and Sweden have taken diverse roads in regard to the provision of formal, public tax-financed home care for older people. Whilst Sweden has cut down home care and targeted services for the most needy, Denmark has continued the generous provision of home care. This article focuses on the implication of such diverse policies for the provision and combination of formal and informal care resources for older people. Using data from Level of Living surveys (based on interviews with a total of 1,158 individuals aged 67–87 in need of practical help), the article investigates the consequences of the two policy approaches for older people of different needs and socio-economic backgrounds and evaluates how the development corresponds with ideals of universalism in the Nordic welfare model. Our findings show that in both countries tax-funded home care is used across social groups but targeting of resources at the most needy in Sweden creates other inequalities: Older people with shorter education are left with no one to resort to but the family, whilst those with higher education purchase help from market providers. Not only does this leave some older people more at risk, it also questions the degree of de-familialisation which is otherwise often proclaimed to be a main characteristic of the Nordic welfare model.     

?konomisierung von Pflege in Gro?britannien, Schweden und Deutschland

This article deals with long-term care policies in three different welfare and long-term care regimes. Despite of divergent regime assignments—Great Britain: liberal welfare state und means-tested long-term care regime, Sweden: social–democratic welfare state and social services long-term care regime, and Germany: conservative–corporatist welfare state and subsidiarity long-term care regime—all three countries restructured their long-term care policies during the 1990s in the context of neoliberal economization and marketization. All countries introduced efficiency-oriented measures, foster competition between different social service providers, and increase choices of people in need of elderly care. By analyzing the regulation of long-term care policies since the National Health Service and Community Care Act (1990) in Great Britain, the ?del reform (1992) in Sweden, and the introduction of the long-term care insurance (1994) in Germany, it can be shown that specific, national pathways, which due to the divergence of regimes and the specific long-term care problems within a country, have evolved.     

Ageing in the Netherlands: Structural and cultural characteristics

This article discusses the specific situation of social policy for the elderly in the Netherlands. On the one hand, due to a prolonged high birth rate after the Second World War, the proportion of the aged is relatively moderate in comparison with surrounding countries. On the other hand, more aged people live in intramural institutions than in other countries, which contrasts with the availability of informal care, resulting from the relatively large proportion of younger persons. Some possible explanations for this paradoxical situation are explored, especially the competition between the different social "pillars" in Dutch society during the expansion of the welfare state.     

Inquiry into the ideal function of the pharmacy in home care*

Background: The aim of this study is to analyze why home‐care services provided by pharmacists have not been effectively utilized. Method: Questionnaires were submitted to home‐care service users, physicians, visiting nurses and home‐helpers and pharmacy directors. We studied whether gaps existed between users’ needs, physicians’ expectations of pharmacy services and pharmacists’ awareness of the importance of pharmacy services. We also investigated whether a failure to recognize the importance of cooperation with pharmacists in home‐care provision existed among physicians and nurses/home‐helpers. Results: Users and physicians expect pharmacists to be more involved in counseling about home care and welfare services than home‐visiting services. Pharmacists recognize home visiting services as being of greater importance than counseling about home care and welfare services. The results indicated that gaps existed between users’ needs, the physicians’ expectations and pharmacists’ awareness of the importance of pharmacy services. In terms of cooperation with pharmacists, study results implied that: (i) nurses/home‐helpers’ awareness of pharmacists’ home‐visiting service is lower than that of physicians; (ii) physicians’ expectations regarding pharmacists’ participation in home care services is lower than that of nurses/home‐helpers; (iii) over 70% of both groups recognize the necessity of pharmacists’ home‐visiting service. Conclusions: Pharmacists need to get more involved in counseling users about home care and welfare. Also, there should be a special focus on heightening nurses/home‐helpers’ awareness of pharmacists’ home‐visiting service and on raising physicians’ expectations for pharmacists’ participation in home care services to develop home‐care related pharmacy services in Japan.     

Older immigrants’ use of public home care and residential care

The purpose of this paper is to analyse the extent to which length of residence in the country and country of origin are of importance to older immigrants’ use of long-term care services compared to native older people. The analyses were conducted on a population of over 65s living in the Municipality of Copenhagen on 1st Jan 2007. Information was drawn from the administrative registers of the Municipality of Copenhagen on the population’s use in 2007 of home care and of residential care in a nursing home. These data were combined by Statistics Denmark with demographic data, socio-economic data and data on the use of health services. It was found that older immigrants are less likely than ethnic Danes to use municipal long-term care services when other predisposing, enabling and need factors are controlled for. The difference is greatest between ethnic Danes and immigrants from non-western countries who have only lived in Denmark for a few years. The difference decreases the longer the immigrant has lived in the country. The findings may be explained, at least in part, by poorer language skills and poorer knowledge of the Danish welfare system among older immigrants and the fact that they are more likely to be cared for by relatives than ethnic Danes are. However, in the course of time language skills improve and knowledge of the system increases and life style with respect to care may approach that of older Danes.     

Analyses of welfare-state reform policies towards long-term senior care in a cross-European perspective

The aim of this article is to introduce a systematic, structured conceptual framework for the comparative analysis of welfare-state reform policies towards long-term senior care and the care structures in a cross-European perspective. A welfare state’s policies on the long-term care of senior citizens frame the different aspects of their care: the care options of the older people, the employment situation of the different types of caregivers and the care quality. The actual structure of senior care is mainly based on the specific care-provision mix in a welfare state and on the main types of care employment. It is should not, however, be treated as a direct outcome of care policies in analyses of welfare-state policies, since the care recipients and care givers all act within the broader framework of the complex and often contradictory cultural, institutional, social and economic context—the specific ‘care arrangement’ of a country.     

Retirement age caregivers and deprivation of area of residence in England and Wales

Many countries in Europe are beginning to acknowledge the essential contribution of informal caregivers, as policy changes leave more people with greater needs being cared for in the community. Carers who are themselves retired are a vulnerable group. Compared to caregivers in younger age groups, a higher proportion have pre-existing disease; they may be more vulnerable to the adverse effects of caregiving on health, and many survive on low incomes. This study investigated whether ill health amongst older carers and hours of caregiving were greater in disadvantaged areas of England and Wales. We also estimated the cost of replacing this care with formal services. Data were analysed from the 2001 UK census, relating to 9.2 million males and females of pensionable age living outside of communal establishments in England and Wales. Thirteen percent of people over retirement age (1.2 million) provided care for others, more than half of whom (742,182) reported poor health. Pensioners provided care in all areas; the proportion giving care was higher in low deprivation (advantaged) areas, but both the numbers and proportion of pensioners in poor health providing many hours of care were greater in disadvantaged areas. The annual cost of replacing all informal with formal social care was estimated to lie between 14.8 and 43.9 billion Euros. Older carers are an essential support to welfare systems. If demographic shifts require any substitution of formal for informal care, this will place a significant burden on all areas, with the greatest needs likely to be in the disadvantaged areas. Competing interests: all authors declare that they have no competing interests. Ethical permission was not required.     

Migrants’ motivations to work in the care sector: experiences from England within the context of EU enlargement

Migrant workers are considered an economic utility, especially for secondary labour markets such as that of long-term care. The dynamics of migrant workers across the globe are governed by interacting macro, state level, and micro, personal level, factors. On the macro level immigration policies, historical and current political and economic links between countries play a crucial part in such dynamics. On an individual level, choices, actions and motivations to migrate and work in certain labour sectors are entangled with and governed by macro level policies. Since 2003, the enlargement of the European Economic Area (EEA) has enabled employers in the UK to freely recruit staff from EEA countries. This article investigates reported individual motivations and the decision making process while accounting for macro factors, specifically ease of labour mobility within the EEA versus a more elaborate process when migrating to work in social care in the UK from outside the EEA. Face to face interviews were conducted with 96 migrant social care and social work staff in six diverse areas of England (2007–2009). The analysis indicates differences in stated motivations to migrate to the UK and to work in the care sector among different groups of migrants, particularly among those from Commonwealth countries, from the EEA, and migrants from other parts of the globe. The findings highlight the importance of taking into account the role of immigration policies and consequently immigration status when investigating the policy framework and delivery of care services for older people.     

HIV, aging and continuity care: strengthening health systems to support services for noncommunicable diseases in low-income countries

Although health systems in most low-income countries largely provide episodic care for acute symptomatic conditions, many HIV programs have developed effective, locally owned and contextually appropriate policies, systems and tools to support chronic care services for persons living with HIV (PLWH). The continuity of care provided by such programs may be especially critical for older PLWH, who are at risk for more rapid progression of disease and are more likely to have complications of HIV and its treatment than their younger counterparts. Older PLWH are also more likely to have other chronic noncommunicable diseases (NCDs), including hypertension, diabetes, cancers and chronic lung disease. As the number of older PLWH rises, enhanced chronic care systems will be required to optimize their health and wellbeing. These systems, lessons and resources can also be leveraged to support the burgeoning numbers of HIV-negative individuals with chronic NCD in need of ongoing care.     

Patterns in the institutional encounters of problem drinkers in a community human services network

It is useful to view the social handling of alcohol problems in US communities from the perspective of a whole network of human service systems that share in the burden of identifying and responding to problem drinkers. This analysis examines the management of alcohol problems in different community service systems by mapping patterns in the institutional encounters of problem drinkers across alcohol treatment, drug treatment, mental health treatment, social welfare and criminal justice systems in a single US community. Findings highlight the prominence of large bureaucratic systems for social welfare and criminal justice as sources of referrals for smaller service systems offering treatment for alcohol problems. However, large proportions of problem-drinking service recipients in the community remain exclusive clients of the welfare and criminal justice systems, making no contact with therapeutically orientated service settings. Compared with problem drinkers who obtain treatment services, problem drinkers on the case-loads of criminal justice and welfare agencies tend to be younger, of higher socio-economic status, are more likely to be male, and tend to drink less heavily and to experience fewer symptoms of alcohol dependence. Given the distinctive characteristics of problem drinkers found exclusively in criminal justice and welfare settings, it may be advisable for communities to introduce early intervention programs in these systems that target services to this particular subgroup of problem drinkers.     

The future of medical rehabilitation in accordance with SGB V and SGB XI in the context of changes in the German Medical Care System

During recent years the German federal social welfare system has been subject to several changes due to structural reforms. The hospital sector--as an element of this system--has also been affected. Based on various legislation the financial framework has been reduced which has led to tendencies of economic limitation and rationalization. From this background considerable risk selection and changes in emphasis might result. Cost intensive patients with a high need for treatment are referred as quickly as possible and discharged to outpatient services despite unknown domestic follow-up care. Mostly the elderly are affected. Medical rehabilitation can be found in this system at the cut between SGB V and SGB XI. However, this division raises problems and discussions concerning benefit payment (rehabilitation before nursing, priority of home, etc.). Right in rehabilitation the most important thing is an overlap of sectors. Various medical, nursing and other social supplies have to be put into a network to achieve an integral treatment of patients that focuses on the individual situation.     

A comparison of the British and German of community care reaction on ethnic minority senior citizens

In Germany, 'Ethnicity and Age' is a central topic of demographic and social change and has become an important issue within gerontological/social political discourses and also a large challenge for existing structures of community care for the elderly. So far, on the scientific as well as the practical level, only a few attempts have been made in Germany to take a look at the experience of other countries. Based on the author's thesis, the following essay aims to bridge this gap. Within the broader context of comparing different welfare systems, it analyzes and compares specific experiences in the field of developing and opening up social services for elderly from black and ethnic minority groups in Germany and Great Britain. Focus is placed on the comparison of life situations of black elderly and legal frameworks of community care for elderly.     

Soziale Ungleichheit in der ambulanten Pflege

Social inequality in Germany is discussed primarily with regard to educational or social welfare issues. There is a political consensus that more action should be taken to ensure equality of chances and fulfillment of basic needs for everyone. In long-term care these considerations have not yet taken place and there are hardly any research studies in this field. However, the startling rise of the need for long-term care will definitely require a discussion of social inequality in various care arrangements. To learn more about social inequality in home care, a qualitative approach was used and 16 home care nurses were interviewed. Our study shows that many care recipients face numerous problems they cannot handle on their own, which may even worsen their situation. In addition, the results reveal that facing social inequalities place a burden on nurses and influence their work performance.     

A German-Israeli Comparison of Informal and Formal Service Use Among Aged 75+

The paper focuses on filial norms and attitudes of older people about the care system of welfare states. It is a further investigation of the OASIS cross national study and examines three questions: First, what do older people in Israel and Germany consider to be the proper balance between the family and the welfare state regarding elder care? Second, what are the responsibilities of the family, the welfare state and other caregivers? Third, in what way do values, filial norms and personal resources relate to actual service use? The empirical data is based on information gathered from respondents living in Israel and Germany, aged 75+. The results of the study indicate that familial help has not been fully replaced by welfare state services. These findings support the complementary perspective. The results also show that most respondents favour a shared responsibility between the welfare state and the family. The findings indicate that familial norms are stable and strong as expressed by elders in both countries. The health situation is the main factor for receiving welfare services and familial help in Israel. In Germany the strong effect of living alone for receipt of welfare services underscores the influence of older adults’ social and personal resources on actual service use. The article discusses the findings referring to the importance of a combined mix of the different sources of help for social policy implications.     

Erfahrungen von pflegenden Angehörigen älterer Menschen in Europa bei der Inanspruchnahme von Unterstützungsleistungen

This article presents selected findings of the EUROFAMCARE research project, reporting up-to-date information on the use and accessibility of support services for family carers of older people in six European countries representing different typologies of welfare systems (Germany, Greece, Italy, Poland, Sweden and the UK). Data were collected by means of face-to-face interviews to national samples of about 1000 family carers per country (i.e. 6000 in total), based on a common recruitment and data collection protocol. The reported findings reveal the crossnational usage of different support services - subdivided for comparative reasons in the categories of socio-emotional support, information, respite care, training and assessment services - as well as of available care allowances. The analysis includes the perceived experience of carers in using them, in terms of costs sustained, factors affecting service accessibility - i.e. main obstacles and greatest helps in accessing them - as well as reasons for not using (needed) services or for stopping using (still needed) services. Cross-national differences are relevant, showing a greater availability in Northern European countries, where however higher refusal rates by potential users of available services are recorded, possibly in connection to their lack of flexibility and low customization.     

A model for integrated home care of frail older patients: the Silver Network project. SILVERNET-HC Study Group

Home care programs for the treatment of frail elderly have been developed in many countries around the world. In the Silver Network project all services are provided in an integrated fashion by one "single entry" center, differently from the traditional fee-for-service or not integrated systems. The delivery of health and social services for frail elderly individuals are integrated and coordinated by a case manager who uses a "second generation" assessment instrument, the Minimum Data Set for Home Care (MDS-HC). We describe the principal clinical and functional characteristics of nearly 1300 patients admitted between 1997 and 1998 to such an integrated home care program in eleven Italian Health Agencies. The database, derived from the serial MDS-HC assessments of each patient, provides a unique opportunity to delineate the different criteria for eligibility for home care, and compare the selected populations of the participating Health Agencies.     

Japan's universal long-term care system reform of 2005: containing costs and realizing a vision

Japan implemented a mandatory social long-term care insurance (LTCI) system in 2000, making long-term care services a universal entitlement for every senior. Although this system has grown rapidly, reflecting its popularity among seniors and their families, it faces several challenges, including skyrocketing costs. This article describes the recent reform initiated by the Japanese government to simultaneously contain costs and realize a long-term vision of creating a community-based, prevention-oriented long-term care system. The reform involves introduction of two major elements: "hotel" and meal charges for nursing home residents and new preventive benefits. They were intended to reduce economic incentives for institutionalization, dampen provider-induced demand, and prevent seniors from being dependent by intervening while their need levels are still low. The ongoing LTCI reform should be critically evaluated against the government's policy intentions as well as its effect on seniors, their families, and society. The story of this reform is instructive for other countries striving to develop coherent, politically acceptable long-term care policies.     

Analysis of comprehensive geriatric assessment of elderly residents in a social welfare home for the aged compared with those in a residential care home in an urban area in Japan

Background:   The purpose of the present study was to clarify the influence of the socioeconomic factors during the middle age on the results of comprehensive geriatric assessments in later stage of life.
Methods:   A cross-sectional, questionnaire-based study was conducted of elderly residents in a welfare home for the aged in Osaka and those in a residential care home in Kyoto. Results of questionnaires pertaining to activities of daily living (ADL), quality of life (QOL) and a 15-item Geriatric Depression Scale as well as medical and social histories of the two groups were compared by unpaired T -test and χ² test.
Results:   Elderly residents in the welfare home were significantly younger and more were both male and unmarried or divorced than among those in the residential care home. Scores in ADLs and QOLs were significantly lower and the prevalence of depression was significantly higher in residents in the welfare home than in the residential care home.
Conclusion:   The ADLs, mental mood and subjective QOLs of residents in the welfare home were significantly lower than those of residents in the residential care home. The reason for these differences is suggested to be due to both the differences in the lifestyles of the residents in their middle age and the difference in the quality and quantity of care the residents are receiving. Local social welfare government should pay more attention to lower ADLs and QOLs of residents in welfare homes and increase efforts to improve the quality and quantity of care for them.     

Lesbian,Gay, Bisexual,and Transgender Aging Concerns

Lesbian, gay, bisexual, and transgender (LGBT) elders and long-term couples have become more visible and their special concerns about aging are being recognized by gerontologists. LGBT elders are a diverse group with regard to all characteristics. This article focuses on the characteristics, research needs and barriers, service needs and barriers, clinical implications, and suggestions for appropriate treatment to increase awareness of clinical gerontologists who may not be familiar with LGBT seniors or who wish to improve their services to this population. Gerontologists working in long-term care facilities and those working in social and home care services may be especially interested in the special concerns of transgender elders and the recent changes in public policy regarding all LGBT elders.