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Los desafíos cuidados de larga duración

The challenges of long-term care for the elderly in Europe

Gloria Fernández-Mayoralas, Group for Research in Ageing – Spanish National Research Council Institute of Economics, Geography and Demographics, Madrid.

Within a demographic scenario of an ageing population and an increase in longevity, long-term care (LTC) for elderly people poses a series of significant challenges for the Europe of welfare states. These challenges are related with the sustainability of the care system, the dual nature of the physical environment where care is provided (home-based or institutional), the social setting (formal provision by professionals or informal provision by relatives, immigrant carers and volunteers) and the origin of funding (public, private, subsidised). All this ties in with the very definition of LTC, its component elements (fragility, illness, dementia, chronicity, acute episodes, etc.) and the need for adequate coordination between the health services and the social services in the dependent care area. This is the context surrounding the two books reviewed here.

The first of the two, Long-Term Care in Europe (2013), focuses on the search for answers to the challenges of LTC arising from demographic change, from transformations in social and family structures, and from the technological revolution, along with the need to evaluate and, where applicable, guarantee or improve the quality of the care provided. With authors from a wide variety of disciplines the book defines the fundamental principles that characterise LTC. It considers prevention and rehabilitation in LTC as a basic and vital need for elderly people and the importance, within the legislative framework, of adequately tackling issues such as the rights of informal carers, including immigrant workers, and family ethics. Other issues covered in the book are related with the need to deal with the problems that appear in the relationship established between formal and informal care and between health and social care. Finally it assesses the usefulness of reviewing solutions offered based on the progression and improvement of policies designed for this purpose.

The book deals with these issues in cross-cutting and comparative thematic chapters, as a result of approaching the question studied through a work plan based on a research project, funded by the European Union’s 7th Framework Programme, with a consortium formed by 13 EU member states. This work has been possible because both objectives and methods were established in advance, and the outcomes of the practical examples were evaluated following a standard template, all coordinated from an inter-governmental organisation affiliated to the United Nations (The European Centre for Social Welfare Policy and Research, www.euro.centre.org) which is based in Vienna.

In contrast, Long-term Care for the Elderly in Europe (2017) is articulated around a chapters structure that responds to a selection of countries, following the classic welfare state typologies, with examples from the Nordic, Central-European, Liberal and Southern and Eastern European models. Also the product of a multi-disciplinary group of authors, in this book the objective is to analyse the organisation, structure and provision of LTC, and the social investment perspective, for each country. This involves examining how they have tackled the challenges and what type of transformations the states have undergone, above all, following the economic crisis. An increase in the elderly population and in the number of fragile elderly people is reflected as spending pressure on the public sector, so privatisation and commercialisation have been part of the evolution of the welfare state, also in the case of LTC, and one of the explicit objectives of social policies, above all in the Nordic and liberal models. Thus, to date, LTC has not been as highly institutionalised as other social services because, despite differences between countries, it has been shouldered to a large degree by civil society, especially families.

Long-term care has been shouldered to a large degree by civil society and, above all, by families.

According to the results offered by the book, in all countries analysed the tendency is converging towards civil society’s participation as a supplier of LTC, with the use of new technologies to favour elderly people remaining in their homes. However, despite all the positive implications of civil society’s participation in the system, it is highlighted that this could lead to inequalities in the provision of LTC, especially among the more fragile receiving population. It could also lead to gender inequalities, given that women have a greater life expectancy, therefore it is more likely that they will not have a partner to care for them when they become dependent. Thus, the balance between individual and bespoke solutions and the ability to remain as long as possible in one’s own home and maintain a satisfactory social life without overburdening a relative continue to be the challenges of LTC.

Whereas in Leichsenring et al. (2013) the classical welfare state model typologies are used, in this case (Greve, 2017) an adaptation has been made from five basic  to four, with demand and formal and informal provision for LTC, defining a standard or mixed care type, a second, Nordic care type, a more family-oriented type and finally, a type called “transitionbased”. In the work, following the comparative study, it is recognised that, in addition to not being an exclusive typology and having different degrees of overlap, notable differences also exist according to the degree of implementation of LTC. Thus, it is highlighted that the United Kingdom, Denmark and the Netherlands would show significant elements of approaches based on holistic, personfocused care; Central European countries such as German and Austria, would still be in the phase of discussion regarding these approaches; while the countries of Eastern and Southern Europe would still be in the search process for the general development of their LTC systems.

Trusting almost exclusively in the family as long-term care provider entails the risk of increasing inequalities.

In short, these two interesting books coincide on tackling the LTC challenge, taking into account numerous dimensions as well as the points of view of both receiver and supplier of the service. However, the first (Leichsenring et al., 2013), based on a cross-cutting and comparative approach, offers a more conceptual view, with the idea of planning a European LTC model with evidence-based results from joint research. Meanwhile the second book (Greve, 2017) is geared more towards the characteristics of LTC in each of the countries analysed (Denmark, Finland, Germany, United Kingdom, Greece, Italy, Portugal, Hungary, Lithuania and Poland), and follows the classical typology of diverse welfare state models, describing the particularities of LTC in each state, to conclude with a chapter containing reflections on the elements common to all the states.

The fact that there is a gap between the publication dates of the two books, 2013 and 2017 (more significant when one bears in mind that the first is based on a project that ran from 2008-2011), adds interest to following the evolution of this area of knowledge and tackling the challenges that are raised. In the 2013 publication, the impact of the economic crisis is not a core aspect and is barely made explicit, thus meaning that the aim of the research is the overcoming of the challenges presented by LTC. Meanwhile in the 2017 publication, it appears as unquestionable that LTC continues to be a newcomer element in social policy and is often only recognised as an element of social pressure, highlighting the fact that the economic crisis has brought with it austerity measures and recourse to private systems (families, and above all women) or commercialised ones, in order to tackle its funding within a scenario of growing expenditure.

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