Cash for long‐term care: Policy debates,visions, and designs on the move

Cash‐for‐care (CfC) schemes have introduced a key transformation in long‐term care policies across Europe since the 1990s. The article explores the extent to which CfC policies have changed over time and into which directions, the ways in which change (if any) has occurred and the forces underlying it. By combining the literature on institutional change with ideational approaches, the article focuses on policy theories and policy designs, on modes of change and factors pushing for change within the CfC policy, and in the long‐term care and neighbouring policy fields. In doing so, we aim to contribute to understanding institutional change and the transformation of an increasingly important sector of the welfare state.     

Cash for care and care employment: (Missing) debates and realities

The introduction of cash‐for‐care (CfC) schemes in different European countries over the last years has responded to a plurality of strategies aimed at attending the rising demand and increasing costs of the long‐term care needs of an ageing population. The specific system of care provision in each country shaped the response given to those challenges, as well as the room for manoeuvre for policymakers when trying to transform the domain of care into a sphere where markets may play a larger role, partly relieving families, and also the state, from these responsibilities. Policy debates and scholarly analyses largely overlooked the contribution of these schemes to the creation and shaping of employment. This article provides a comparative analysis of how CfC‐based policies entail—alongside the regulation of informal care—a(n implicit or explicit) connection with care employment and may contribute to structuring employment relations in this sector. It looks jointly at the specific features of CfC and at the institutional context—welfare regime—in which they are embedded in order to assess the extent to which these schemes contributed (generally unintendedly) to a transformation of the care employment size and features in seven European countries.     

Older Persons’ Views on Using Cash‐for‐Care Allowances at the Crossroads of Gender,Socio‐economic Status and Care Needs in Vienna

The article aims to contribute to understanding social inequalities resulting from familization (or de‐familization) tendencies among cash‐for‐care beneficiaries in a Conservative welfare state. It highlights justifications for choices in accessing and using care in a cash‐for‐care scheme from the perspective of care recipients aged 80 years and older in Vienna. Along key dimensions characterizing care recipients’ experiences, we identify four different user groups, which reflect recipients’ individual characteristics, particularly gender, socio‐economic status (SES), and care needs, and the respective care arrangement. The groups are dubbed: (1) the self‐confident; (2) the illiterate; (3) the dependent; and (4) the lonely. Narrative interviews with 15 frail older people were held in 2014 and analyzed using the framework analysis method. Results show that familiarity with support structures associates with higher SES, while those who depend on others for acquiring information or organizing care express ambivalence in choosing between formal and informal care. Engagement in deciding which care type to use is limited among people of lower SES or with complex care needs, but own experience as informal caregiver for a family member increases care recipients’ long‐term care (LTC) system literacy. Gender differences among care recipients were limited, yet middle‐class female recipients often expressed normative claims for family care from female relatives. We conclude that unconditional care allowance schemes may reinforce existing gender relations, particularly among informal caregivers, as well as underpin socio‐economic differences among LTC users in old‐age. Results also partly question the assumptions of choice and empowerment implicit in many cash‐for‐care schemes.     

Marketisation policies in different contexts: Consequences for home‐care workers in Germany,Japan and Sweden

Market‐oriented restructurings of long‐term care policies contribute significantly to the aggravation of care workers’ situations. This article focuses on the effects of broader long‐term care policy developments on market‐oriented reforms. Germany, Japan and Sweden are three countries that have introduced market‐oriented reforms into home‐based care provision embedded in distinct long‐term care policy developments. Conceptually, this article draws on comparative research on care to define the institutional dimensions of long‐term care policies. Empirically, the research is based on policy analyses, as well as on national statistics and a comparative research project on home‐care workers in the aforementioned countries. The findings reveal the mediating impact of the extension and decline of long‐term public care support and the corresponding development of the care infrastructure on both the restructuring of care work and the assessments of the care workers themselves.     

Differences and similarities in monetary benefits for informal care in old and new EU member states

This article presents an overview of the monetary benefits available in the context of long‐term care provided by family or other informal carers in 11 old and 10 new EU member states. All but one country in our sample offer at least some monetary benefits that can be used to help finance informal care. Old EU member states tend to direct benefits to individuals in need of care, whereas new EU member states place more emphasis on benefits for carers. Among new EU member states, monetary benefits are less often means‐tested and tend to be lower compared with benefits in old EU member states. Because social policies in many countries increasingly rely on monetary benefits rather than on benefits in kind and because the share of informal care in the overall provision of elderly care will scarcely decline, monetary benefit incentives for labour market participation need to be carefully monitored.     

Cash‐for‐care payments in Europe: Changes in resource allocation

Resource allocation has been a main policy issue in cash‐for‐care schemes (CfCs) for older people in Europe since their inception. It regards how publicly funded care benefits and services are distributed among older people. The raising pressures of an ageing population and the tensions on the financial sustainability of welfare regimes in place have further exacerbated the relevance of this topic over the recent years. Nevertheless, comparative research so far has overlooked changes in resource allocation in CfCs over time. This article contributes to fill this gap, exploring changes in resource allocation of CfCs for older people in a sample of European countries—Austria, England, France, Germany, Italy, and The Netherlands—since the early '90s (or since the introduction of the scheme). It examines three analytical dimensions: (a) The mix of public services and benefits provided to older people (CfCs, community services in kind, residential care); (b) the level of CfCs coverage; and (c) its generosity. A combined view of these dimensions leads to the discussion of two dilemmas: How to allocate the resources devoted to CfCs in the light of the trade‐off between its coverage and intensity? And, within the whole long‐term care system, how to allocate resources between CfCs and services in kind?     

Introducing social insurance for long‐term care in Taiwan: Key issues

Nadash P, Shih Y.‐C. Introducing social insurance for long‐term care in Taiwan: Key issues Taiwan will shortly complete its comprehensive social safety net, which includes national health insurance, retirement security, and unemployment insurance, by introducing long‐term care (LTC) insurance – putting it ahead of the many countries that rely on a patchwork of policies to address the need for LTC. The program, to be implemented in 3 to 5 years, will cover all citizens on a primarily social insurance basis. The range of LTC policy options considered is discussed, particularly how to structure the program, how to finance and regulate it, and how to develop its inadequate LTC infrastructure and workforce. Particularly thorny issues include the choice of social insurance, the feasibility of cash benefits, and how to address Taiwan's heavy reliance on foreign workers. Taiwan's increasingly democratic character, along with high levels of public support for the program, creates significant pressure on politicians to deliver on their promises to implement LTC reform. Key Practitioner Message: ?Emphasizes the importance of policy learning from other environments; ?Highlights the need for a strong regulatory and provider infrastructure for delivering long‐term care services; ?Emphasizes the need for training, support, and appropriate regulation of the long‐term care workforce.     

Coverage versus generosity: Comparing eligibility and need assessment in six cash‐for‐care programmes

This paper investigates the potential trade‐offs between extension of coverage and adequate generosity in cash‐for‐care (CfC) programmes in six European countries (Austria, Germany, France, Great Britain, Italy, and Spain), which are characterised by different configurations of CfC programmes. Building on an empirical analysis of the eligibility rules, of the regulation applied to classify beneficiaries according to their level of dependency, and the ways CfC benefits are distributed among them, it becomes clear that these programmes differ substantially in terms of coverage and generosity. Such differences reflect the variety of ways by which universalism, selectivity, and adequacy are built up together throughout Europe.     

Regulating the delivery of cash‐for‐care payments across Europe

The article aims to understand how governments across Europe have modified the regulation of the delivery of cash‐for‐care schemes (CfCs) to dependent older people since the beginning of the century. In our terminology, the regulation of the CfCs delivery defines the norms, rules, and practices that public actors adopt to manage how beneficiaries can use the benefits. To discuss the regulation of CfCs delivery, we employ an original framework that take three analytical dimensions into account: the degrees of freedom in benefits' utilization (“CfCs utilization” dimension), the provision of information/orientation/advices/counselling to older people and families (“professional support” dimension), and the relationship between the delivery of CfCs and the delivery of the other publicly funded long‐term care inputs (“care system” dimension). The analysis adopts a comparative perspective, looking at six countries—Italy, Austria, the Netherlands, France, Germany, and England. Among various findings, the main one consists in showing that there has been a shared and increased interest in consolidating the regulation of CfCs delivery. This trend has been mostly directed towards the new policy aim of strengthening the professional support, a goal underestimated in the past, when this dimension was not a major topic of both debate and practice concerning CfCs across Europe.     

Person‐centredness in the community care of older people: A literature‐based concept synthesis

‘Person‐centredness’ is a ubiquitous term, employed in modern care services to signify policies and practices that attend to the uniqueness of each individual user. Despite being highly regarded in older adult community care services, there is much ambiguity over its precise meaning. Existing reviews of person‐centredness and its attributes have tended to focus on the medico‐nursing literature, neglecting other interpretations, such as those relevant to community social care. A new literature‐based concept synthesis reported here identified 12 common attributes within the broad themes of ‘understanding the person’, ‘engagement in decision‐making’ and ‘promoting the care relationship’. The review also contrasts how these attributes are applied across different interpretations of person‐centredness. The article argues that not all attributes necessarily pull in the same direction, and that older adults may require them to be delivered in different ways than they are to younger people. Thus, a ‘one‐size‐fits‐all’ approach should be discouraged in community care. Key Practitioner Message: ? ‘Person‐centredness’ is open to multiple interpretations, causing difficulties for services trying to gauge performance and quality; ? Three themes are central to person‐centred services: ‘understanding the person’, ‘engagement in decision‐making’ and ‘promoting the care relationship’; ? A ‘one‐size‐fits‐all’ approach to applying person‐centredness is to be discouraged.     

Needs and availability of support among care‐leavers: A mixed‐methods study

Data are scarce on the long‐term needs of care‐leavers and on the support resources that are available for them in the years after leaving care. This mixed‐methods study presents data on the needs and availability of support of 222 Israeli care‐leavers, suggesting that the most urgent needs of care‐leavers are a lasting need for a stable and available support figure and assistance with educational issues. For some care‐leavers, these needs are fulfilled by their mentors. Parents and other familial figures were found to be the most common support resource for care‐leavers, which highlights the need for the intervention of social workers to improve relationships within families while the children are still in care. Due to high rate of young people who have no support resources and a low rate of services utilization, social services should provide a platform to support this group, using mentors and other supporters. The longitudinal data of up to 4 years after leaving care indicated that the availability of various types of informal support improved over the years, and the reports on difficulties in relationships of the care‐leavers with their parents were significantly fewer 4 years after leaving care than on the verge of leaving care.     

Contextualising institutional complementarity. How long‐term unemployment depends on employment protection legislation,active labour market policies and the economic climate

This study investigated if and how active labour market policies (ALMPs) and employment protection interact with each other in light of long‐term unemployment reduction. We argue that how well the interaction between both labour market institutions reduces long‐term unemployment depends on the level of economic growth. To improve analytical clarity, two types of ALMPs were differentiated, namely training and employment programmes. Using data on 20 European countries over 16 years, our results suggest that employment protection moderates the relationship between employment programmes and long‐term unemployment. The combination of high spending on employment programmes and less strict employment protection is associated with less long‐term unemployment. This moderation effect is stronger during an economic downturn. A moderation effect from employment protection on the relationship between training programmes and long‐term unemployment was not found, even when the economic climate was taken into account as a contextual factor.     

Comfort with discussions about death,religiosity, and attitudes about end‐of‐life care

In end‐of‐life (EOL) care research, death anxiety and religiosity are often overlooked. Terror management theory (TMT) may provide a useful conceptual model with which to examine how comfort discussing death and religiosity influence attitudes related to EOL care. A telephone‐based survey was conducted among community‐dwelling adults in the Unites States. Via random sampling, with over‐sampling of Hispanics/African Americans, 123 completed survey interviews (response rate = 46%) were analyzed. Respondents were more likely to have better attitudes toward EOL care if they were older or white, religiously active, and comfortable with the subject of death. Religiosity and comfort discussing death were correlated with each other and remained significant predictors of attitudes about EOL care even without demographic covariates. Findings suggest that promoting an open dialogue about mortality may improve attitudes about EOL care and utilization of palliative care services. The study also provides evidence about the utility and applicability of TMT for EOL care.     

Young care leavers' expectations of their future: A question of time horizon

This paper investigates young care leavers' expectations of their future after discharge from care. The results are based on qualitative longitudinal data where 16‐ to 21‐year‐old care leavers (n = 15) were interviewed twice, first when still in care but planning for their discharge (T1) and the second time 6–9 months later (T2). The analysis using a general inductive approach showed that their expectations were dependent on the time horizon and that there was an obvious difference between the young informants' short‐ and long‐term expectations. Their short‐term expectations consisted of worries connected to their approaching discharge (at T1) and how to cope with challenges of everyday life after discharge from care (at T2). These results seem to echo negative outcomes shown in previous quantitative research. However, the informants' long‐term expectations provide a different picture, being mainly positive in both interviews (T1 and T2). The results are discussed from a life course perspective, where the informants' visions of their future are framed and understood in terms of the different stages of their transition process.     

Child Well‐Being Scales (CWBS) in the assessment of families and children in home‐care intervention: an empirical study

This paper reports research carried out in Italy designed to investigate the usability of Child Well‐Being Scale (CWBS) for the outcome evaluation of home‐care interventions for vulnerable families and children in need. Using a pre‐ and post‐test design, the study traces the changes in 18 vulnerable families and 23 children in need included in a programme of home‐care intervention over a period of 11 months. All the families and children were assessed twice: at intake and at the end of the intervention (after 6 months). Furthermore, 10 families and 11 children had a longer intervention and were assessed three times. Moreover, two focus groups involving 13 home‐care workers and 11 face‐to‐face interviews were used to collect practitioners' points of views on CWBS. The results generally support the idea that families' and children's situation improved over time, as shown by an improvement in almost all of the considered dimensions after 6 months and after 11 months. Specifically, the families improved more on household adequacy in the long term while children on the child performance dimension improved in the short term. Practitioners reported that CWBS was an aid to multi‐professional decision‐making, as the systematic evaluation of the subscales was a practical base upon which to activate shared decision‐making during the casework.     

Migrant Care Work Going Dutch? The Emergence of a Live‐in Migrant Care Market and the Restructuring of the Dutch Long‐term Care System

In recent years, a live‐in migrant care (LIMC) market has emerged in European countries with specific care, migration, and employment regime features. In countries with relatively low levels of formal long‐term care (LTC) provision, people in need of care and their families have started purchasing LTC directly from individual – mostly migrant – workers who live‐in with the person in need of care. Previous research has shown that this arrangement is facilitated by the availability of cash‐for‐care benefits that can be freely used by the beneficiaries, and/or by low levels of regulation of employment and migration. The Netherlands traditionally features strong, universal and generous LTC policies. However, recently, the phenomenon of LIMC has also appeared there. Based on exploratory qualitative research, this article examines the features of Dutch LIMC and the factors that foster or hinder its development. Our findings show that the ongoing restructuring of the Dutch LTC system – particularly the emphasis on informal care and decreasing accessibility of institutional care – are important factors pushing an LIMC market. At the same time, various institutional factors limit its growth, particularly the high levels of regulation of the Dutch care, migration and employment regimes. Further cutbacks in the care sector might push more families to this market in the near future, and change the character of the Dutch LTC sector. The Dutch case is relevant for other countries with longstanding traditions of generous LTC services which currently undergo retrenchment, and sheds light on routes to institutional change.     

Unheard voices,unmapped terrain: Care work in long‐term residential care for older people in Canada and Sweden

Daly T, Szebehely M. Unheard voices, unmapped terrain: care work in long‐term residential care for older people in Canada and Sweden This article aims to contribute to comparative welfare state research by analysing the everyday work life of long‐term care facility workers in Canada and Sweden. The study's empirical base was a survey of fixed and open‐ended questions. The article presents results from a subset of respondents (care aides and assistant nurses) working in facilities in three Canadian provinces (n= 557) and across Sweden (n= 292). The workers' experiences were linked to the broader economic and organisational contexts of residential care in the two jurisdictions. We found a high degree of country‐specific differentiation of work organisation: Canada follows a model of highly differentiated task‐oriented work, whereas Sweden represents an integrated relational care work model. Reflecting differences in the vertical division of labour, the Canadian care aides had more demanding working conditions than their Swedish colleagues. The consequences of these models for care workers, for older people and for their families are discussed.     

Implementing Consumer Choice in Long‐term Care: The Impact of Individual Budgets on Social Care Providers in England

In common with many advanced welfare states, England has increasingly relied on consumerist principles to deliver both greater quality and improved efficiency in the long‐term care system. The Individual Budget (IB) pilots marked the next step in this process, through a new system of funding whereby greater control of resources is given to service users, in lieu of direct in‐kind care provision. IBs have the potential to transform the market for care services as well as the relationships between key stakeholders within it. Purchasing will increasingly be shaped by the demands of IB holders, with providers expected to deliver a wider range of personalized services. What will this mean for providers, and what can they do to prepare for these changes? These questions are relevant not just in England but in many other countries adopting similar mechanisms for devolving control over the design, delivery and funding of care to the end‐user. The article explores the early impact of IBs on providers' services, on their workforces, and on the administrative implications for providers of managing IBs. The study finds that providers were positive about the opportunities for better‐quality services that IBs can bring about. However, participants highlighted a number of obstacles to their effectiveness, and reported a range of potentially adverse administrative and workforce consequences which have the potential to jeopardize the consumerist policy objectives of increased choice and efficiency.     

Stability and change – a 7‐ to 8‐year follow‐up study of mental health problems in Norwegian children in long‐term out‐of‐home care

The aim of the study was to explore stability and change in mental health problems in Norwegian children aged 6–12 years old (n = 70) in long‐term out‐of‐home care. The children's mental health problems were assessed shortly after the placement and 7–8 years later by the caregivers and the teachers on the Revised Rutter Scales. Information on pre‐placement and placement factors were collected from the child welfare workers. At a group level the children's mental health problems had improved significantly over time according to the teachers' reports. According to the caregivers' reports, however, the children's problems were high and stable across time. Analyses aimed at detecting individual changes revealed a great variability in development according to both informants, indicating that treating the placed children as a homogenous group could be misleading. Several pre‐placement and placement variables were associated with the change in the children's mental health problems from the time of placement to the follow‐up time according to both informants' reports. However, all the predictors were accounted for by the strong effect of the children's problem scores when entering care.     

Emotional kinship care and neutral non‐kinship care — the struggle between discourses

In this paper, social workers' ideas of kinship care and non‐kinship care as foster placement alternatives for vulnerable children are analysed and discussed. The study is based on group interviews with Swedish social workers, using a discourse analytic approach. The interviews took two vignettes of children who needed an immediate and long‐term placement because one of the parents had killed the other parent, as their point of departure. Domestic violence is a common social problem across countries, and controversies about placement alternatives become even more apparent when discussing lethal violence. The analysis revealed three main discourses: ‘emotional kinship care’, ‘neutral non‐kinship care’ and ‘a real family’. The emotional kinship care discourse also revealed two competing sub‐discourses: ‘emotions as glue that binds’ and ‘emotions as obscuring a child perspective’, displaying a struggle concerning the advantages and risks that social workers connected to kinship care. In this paper, the results and their implications for vulnerable children are discussed.