care: Norway in a European comparative perspective

Transcription

1 Reforming long-term care: Norway in a European comparative perspective Svein Olav Daatland 1, Julie Kjelvik 2, Berit Otnes 2, Marijke Veenstra 1 1 Norwegian Social Research, Oslo 2 Statistics Norway, Oslo [sod@nova.no sod@nova.no] Presentation at the International Conference on Evidence-based Policy in Long-term Care,, London School of Economics,, September 8-11, 2010.

2 Outline The Context Similar problems, different solutions The Norwegian model The Reforms Aims Means The Outcomes Intended Unintended The future Legitimity Sustainability

3 Similar problems Population ageing Family change Equal opportunities Public finances Welfare regimes: Scandinavian Liberal Conservative Southern e.g. country Norway England Germany Spain Life expectancy women 81,9 80,7 81,1 82,3 men 76,0 78,2 78,2 78,8 Fertility 1,8 1,6 1,3 1,1 Female workrate 72 % 62 % 61 % 45 % Population ageing % ,2 15,2 16,4 16, ,3 25,4 29,7 30,7

4 different solutions Welfare regimes: Scandinavian Liberal Conservative Southern e.g. country Norway England Germany Spain State role Primary (Primary Primary) Subsidiary Subsidiary Major instrument Services Transfers Transfers (Services) Eligibility Universal Selective Selective Selective (means means-tested tested) (family family-tested tested) (family family-tested tested) LTC expenditure 1 2,3% of GDP 1,4% 1,4% 0,6% Public LTC exp. 1 86% 65% 70% 26% User rates: %65+ 2 in institutions 5,3 % 3,5 % 3,8 % 4,1% in home care 19,3 % 12,6 % 6,7 % 4,2% Total 24,6 % 16,1 % 10,5 % 8,3 % Sources: 1 OECD 2005, 2 Huber et al

5 Scandinavian variations: % 65+ with home care and institutional care Source: Huber et al

6 European variations: % 65+ with home care and institutional care Source: Huber et al

7 Recent reforms Administrative Integration of services Decentralization of responsibility Services: De-institutionalization, Ageing in place Assisted housing Community care Home-like institutions Mixed motivations Fair distribution, normalization of care Cost-efficiency, Value for money Controversies Elder care vs Other care Institutions vs assisted housing Public vs private provision Central or local responsibility New Public Management Outcomes

8 De-institutionalization institutionalization? Alternative housing and community care? Housing +70% less than half assisted housing, i.e. with staff Institutions -8% Residential homes - Nursing homes + Total facility +24% More home-like: Single rooms to all in nursing homes Assisted housing replacing residential homes Alternative to institutional care? If so, both housing and community care need be increased. No of residents by type of facility Residents by type of facility and year As sisted housing Res idential homes Nursing homes

9 Ageing in place? Alternative housing and community care? No of users by type of service Home nursing +66% Home care clients by year Home help 15% Home care total +12% Targeting: Personal care (nursing), moderate (social, practical) needs a family responsibility Alternative to institutional care for older people? Nursing only Both Practical only

10 Distribution between elder care and other care No of clients by age : Institutional care Housing Institutions: clients by age and year Ass. housing: Clients by age and year Institutions are for elders only, and in moderate decline. Housing in increase for both older and younger, but only for the younger in combination with increase in home care. Home care In conclusion: Two worlds of LTC Home care: Clients by age and year Institutional care still dominant in elder care, now with 71% of total expenditure Open care dominant for younger groups, now with 85% of total expenditure Assisted housing for elders seldom sufficiently staffed to replace nursing homes. Illness model for elder care?

11 Elder care in summary, relative to needs needs User rates for the User rates for 80+ by type of service and year Lower institution rates (19-14%) Higher housing rates (7-11%) Stable total in facility rate (26-25%) Services in Ordinary housing Ass. Housing Institution Lower home care rate (39-35%), in particular among elders in ordinary housing Lower grand total user rates (58-49%) but higher investments, implying targeting and medicalization: more to the selected few Hesitant to invest in open care for elders, e.g. 4 h per week in average for elders, 12 h for younger users Nursing homes dominated by the dementias The strong position of institutional care for elders Adequate response to needs? Outdated (illness) model?

12 Current (2007) user rates (%) are still high in a European context Institution 6,1 14,0 34,8 Total facility (institution + housing) 11,2 24,6 55,0 Grand total (institution+home care) 23,4 48,3 86,7 Public sector dominance stable, i.e. 90% of institutions User fees moderate and stable: Home help 2% of real costs, Home nursing free, Institutional care 15% of real costs, Housing personal responsibility for rent (subsidized), public provision of services State family balance estimated at 50-50: Family dominance for moderate needs, public dominance for personal care

13 The future? Sustainability: Balancing needs and resources Legitimity: Solidarity on family and societal levels The Scandinavian dilemma: High expenditure and taxes: the solidarity issue? The European dilemma: High demands on families and women: the equal opportunity issue. Responses Modernizing ideas, confronting traditions (path dependency) Converging ideals and practices?