Current Developments in Social Care Services for Older Adults in the Czech Republic: Trends Towards Deinstitutionalization and Marketization

ABSTRACT

Deinstitutionalization and marketization of eldercare has been delayed by 20 years in the Czech Republic compared to Western Europe, and it takes place in a completely different context, characterized by the legacy of communism, a growing older population, and less generous public subsidies. This study is the first in the Czech Republic to examine how deinstitutionalization and marketization effect implementation of these principles on the availability and quality of eldercare services at regional and municipal levels. A mixed-method approach was used, combining several data sources (policy documents, administrative data, statistics, expert panel, and secondary use of qualitative data). The findings suggest that the support for and availability of home-based care has declined, despite the ever-increasing number of older adults and policy preference for deinstitutionalization. Furthermore, home-based services have failed to adjust to growing care needs of older adults (e.g., inflexible schedules, limited provision of time-demanding care, inadequate staff composition). This situation occasioned an unintended outcome: the emergence of nonregistered, semilegal, for-profit nursing homes offering low-quality care and poor working conditions, and subject to no quality control. The health and even lives of older adults are at risk if they choose such services. Research is needed to study older adult decision making and offer them tools to identify and avoid questionable services.     

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.     

Home modification among families with older adults with disability in Korea

Abstract

This study explores psychosocial factors related to the use of home modification among older adults with disabilities and their caregivers in Korea. Using in-depth interviews, this study elaborates specific socio-cognitive factors leading to home modification from the multiple perspectives of care recipients, family caregivers and home care helpers. The study findings are theoretically organised into four domains: structural factors, care recipients’ service needs, socio-cognitive factors, and enabling resources. Practice and policy implications are discussed in the context of underdeveloped housing policies for ageing-in-place in Korea.     

Is home care a realistic alternative to residential care among institutionalized elderly people in Finland?

The high rate of institutionalization among elderly people in Finland is widely discussed among policy-makers. We studied how realistic the wishes for deinstitutionalization are among the least sick elderly people in residential care, and what patient characteristics predict whether residential care is appropriate. This issue was assessed by the residential home personnel. Personnel assessment of institutional care as appropriate was mainly explained by patients' needing help with medication, limitations in activities of daily living, absence of own home to return to, no living children, incontinence, and poor vision. Discharging elderly people from long-term residential care back to society is limited by factors such as inadequate housing and shortage of domiciliary and rehabilitative services, as well as by attitudes among the institutionalized elderly people themselves. It seems more realistic to prevent the inappropriate institutionalization of elderly people than to discharge the small numbers of fairly independent individuals already in residential homes.     

Autonomy,Choice and Control for Older Users of Home Care Services: Current Developments in Swedish Eldercare

In Sweden, a policy shift towards more individualized eldercare, with an emphasis on consumer choice, has taken place. The aim of this study was to analyze the processes and practices of individualized eldercare, focusing on preconditions for older peoples’ choice and control. Data consist of qualitative interviews with users of home care services (n – 12) and staff (n – 12) and participant observations (n – 7) of meetings between staff and older people. The choice and control available to older users emerged as decisions about ‘what’ care and services, ‘who’ should provide the care and services, and ‘how’ the care and services should be performed. Three approaches to enable older people choice and control over their home care services were revealed: test and revise, services elaborated in close collaboration between users, care managers and home care staff; choices in the moment, users could choose services at each occasion; and quality improvement through competition, competing providers develop attractive services. The findings could guide policy makers in combining the strengths of these approaches to enable older people in need of support to become co-producers in designing, managing, as well as consuming, care and services. Future quantitative research is needed to achieve generalizable knowledge about the strengths and weaknesses of different ways to organize eldercare services.     

Policy Changes in Community Mental Health: Interventions and Strategies Used in Sweden over 20 Years

The deinstitutionalization of mental health care has changed the responsibilities of involved authorities and has led to a continuous need for new treatment forms and interventions. This article describes this development in Europe, and in particular how these new conditions have been handled in Sweden over the past 20 years at the level of governmental policy‐making. Three major policy documents from 1994, 2009 and 2012 were included in this study. To increase our understanding of the policies' contents, we have used theoretical concepts concerning governance, implementation and political risk management. Although our main interest was to find out how the government handles interventions for users of the mental health care system, we found that the policy work is progressing stepwise. The first document, from the deinstitutionalization era, did not discuss interventions clearly. Instead, it was mainly concerned with both practical and economical areas of responsibility. The second document, from the post‐deinstitutionalization era, was more focused on what services should be delivered to the users, while the most recently published document to a greater extent addressed the question of how the support is supposed to be designed. The trend in European community mental health policy has been to advocate services in open forms that are integrated into the society's other care systems. This is also the case in Sweden, and continuous work is being done by the government to find strategies to support the development, and to meet the needs at both political and local levels.     

Are there differences in standard of care for the elderly? A comparative study of assistance decisions in Stockholm

According to Swedish law, an elderly dependent person is entitled to public services in the form of home help in ordinary housing or a place in special housing — i.e. sheltered housing, a residential home or a nursing home. There are no explicit rules for how much home help a person is entitled to given dependency and other factors, nor are there any explicit criteria to guide the admission to special housing. A study was performed in ten districts in Stockholm in order to determine whether there were systematic differences between the districts with regard to the allotment of care and services to the elderly. It was found that there were in fact significant differences that could not be explained by variations in dependency or other factors of importance for the allotment decision. A minor part of these differences was connected to the different background and experience of the assessing person.     

Success in agenda setting through failure in policymaking: Exploring a new policy venue in the Polish European Semester 2012–2022

The article presents the results of a case study based on participant observation of a policy venue which was established in Poland as part of the implementation of the European Semester (ES) in 2012. The long period (2012–2022) and the rich material collected by the insider in the studied venue (as a representative of over 30 civil society organisations affiliated to EAPN Poland) provide a unique opportunity to gain insight into the participation of social actors in the coordination of economic and social policy in the European Union after 2010. The main research question addressed in the article is: why did social actors gain influence on the agenda of the policy venue, but not on national social policy? Social actors participating in the European Semester in Poland, despite strong and competent representation in the policy venue under consideration, and despite their collaboration with other stakeholders, did not directly influence national poverty reduction policies. However, they strongly influenced the agenda of the policy venue, establishing poverty as a permanent item in the agenda of the subsequent ES cycles 2014–2019. The explanation of this course of action is the institutional framework of the policy venue studied in this article, the policy advocacy strategy adopted by the social actors within it in 2013–2015 and the institutional events triggered by the pandemic in 2020–2022.     

Compulsory intergenerational family solidarity shaping choices between work and care: Perceptions of informal female carers and local policymakers in Estonia

Estonians are obliged by law to provide maintenance for family members who are unable to cope by themselves. As a result, 80% of fragile older people receive informal care. Whether this is because the carers themselves feel solidarity and choose informal caring or because they lack alternatives is the question. We applied the cultural approach for explaining the construction of compulsory family solidarity in care provision to older people through the perceptions of informal carers and policy actors. Our interest is in how filial norms framed by individual responsibilities of care provision required by law can influence (i) informal carers’ perceptions concerning their choices between work and care and (ii) impact policy actors’ perceptions concerning eldercare service provision. Analysing the empirical data produced during focus groups with female carers and interviews with policy actors, we demonstrate the triple‐fold pressure to informal caregiving as an expression of compulsory family solidarity. Key Practitioner Message: ? The article demonstrates how the national Family Law Act constitutes a compulsory requirement of family solidarity in society; ? The compulsory family solidarity norm influences local‐level policymaking and inhibits the development of formal care services for older people; ? Informal carers’ choices between work and care are shaped by their personal filial norms, familialistic policymaking, and pressure exerted by older people.     

Sheltered Housing and Community

This paper considers the role of sheltered housing following the introduction of new community care arrangements in 1993 and examines the continuing uncertainty about its exact role as community care continues to develop. It reports on a study conducted in Shropshire, using a postal survey and interviews with older people and service professionals. The study highlights the importance of sheltered housing for older people, particularly in relieving them of concerns about maintenance and repairs, social isolation and security. These factors were crucial for their overall peace of mind and quality of life. While only a small proportion of tenants received help under social services' community care arrangements, the additional support, monitoring and service coordination provided by wardens helped some of them to remain in sheltered housing when residential or nursing home care might otherwise have been necessary. Sheltered housing was overwhelmingly popular with older people — but their satisfaction was closely associated with the availability and quality of the warden service. Although sheltered housing is not currently in vogue in housing policy, the paper argues that it plays a vital role in local provision for older people and needs to be more closely integrated into community care policy, while at the same time preserving the characteristics that make it popular with its residents.     

Devolution and Patient Choice: Policy Rhetoric versus Experience in Practice

Background: market reforms in England have been identified as making a clear distinction between English health policy and health policy in the devolved systems in Northern Ireland, Scotland and Wales. Patient choice is a high profile policy in the English National Health Service that constitutes significant changes to the demand side of health care. It is not clear what national differences this has led to regarding implementation of policy. This article presents the findings from a large UK‐wide study on the development and implementation of policies related to patient choice of provider. The findings reported here relate specifically to the policy development and organizational implementation of choice in order to examine the impact of devolution on health care policy. Aim: this study examines patient choice of provider across all four countries of the UK to understand the effect of differences in national policies on the organization and service how choice of provider presented to patients. Methods: at the macro‐level, we interviewed policymakers and examined policy and guidance documents to analyze the provenance and determinants of national policy in each UK nation. At the Primary Care Trust or Health Board level, we interviewed a range of public and private health service providers to identify the range of referral pathways and where and when choices might be made. Finally, we interviewed ear, nose and throat, and orthopaedics patients to understand how such choices were experienced. Findings: while we found that distinct rhetorical differences were identifiable at a national policy level, these were less visible at the level of service organization and the way choices were provided to patients. Conclusion: historical similarities in both the structure and operation of health care, coupled with common operational objectives around efficient resource use and waiting times, mediate how strategic policy is implemented and experienced in the devolved nations of the UK.     

The Deinstitutionalization of Children in Bulgaria – The Role of the EU

In this article, the role of the EU as a key factor for the development of the deinstitutionalization of children is explored. A series of hypotheses concerning EU funding, policies and politics are addressed with regards to how the EU as a whole has affected the deinstitutionalization of children. The article explains the presence of association between instigation of public interest and civil mobilization and the launch of a nationwide reform – in particular how advocacy both at national and EU level led to the adoption of a national reform strategy in Bulgaria. Further, the association between the availability of an innovative approach to spending the EU funds and the decision generally to reform the system for institutional care for children is presented. The article explains the difference that €107.6 million will make for Bulgaria's abandoned children if the European structural funds are realized with their full potential. On the other hand, it reveals the challenges that the process is facing. A great deal of non‐governmental organization (NGO) experience concerning EU involvement in the process has been generalized and construed in order to achieve the best possible understanding of the whole process, the key players and the fundamental issues.     

Choosing Welfare or Losing Social Citizenship? Citizens' Free Choice in Recent Italian Welfare State Reforms

In the past fifteen years, the Italian welfare state has gone through various important reforms. Almost all social policy fields have been significantly challenged by the presence of both national and European constraints, and in different policy fields some fundamental principles of the welfare state have been questioned and changed. The purpose of this article is to present an analysis of the most recent arguments used for welfare state reforms in Italy, focusing in particular on one key question: have the reforms been formulated and implemented in order to increase the freedom of choice of Italian citizens with respect to social protection? After a brief introduction and conceptual clarification, each section of the article will focus on one social policy field (employment, pensions, health care) and discuss the origins and consequences of the reforms with respect to the freedom of choice of citizens. The main argument is that very limited attention has been paid in the national political discourse and reform design to the freedom of choice for citizens in welfare state policies, since other goals (such as cost containment) were much more crucial. The article will end with an overall assessment of the evolution of freedom of choice in the Italian welfare state setting.     

An exploration of the differential usage of residential childcare across national boundaries

The use of residential placements for children needing out‐of‐home care remains controversial. This article considers the discourse of ‘residential’ and ‘institutional’ care before describing, mainly through administrative data sources, the wide variations in group‐care usage in different jurisdictions. In some countries, its use is minimal, with foster care, kinship care and in some cases, adoption being the preferred options. This is not so in other countries where a high percentage of children in care are in residential placements. There is also diversity in the type of residential services, ranging from small group homes to large institutions. The challenges inherent in making process and outcome comparisons across national boundaries are explored. The authors concur with those who argue for more systematic ways of describing and analysing the aims and characteristics of residential settings. Only then can meaningful comparisons be made between outcomes from group‐care regimes in different jurisdictions.     

‘Problematising’ Australian policy representations in responses to the physical health of people with mental health disorders

Australia, like other jurisdictions, is recognising the poorer physical health of people with mental health disorders. This paper explores policy responses to this issue through discourse analysis of 22 Australian Federal and State government policy documents published in 2006–2011. The paper utilises Bacchi's ‘what's the problem represented to be?‘ approach to explore policy solutions in relation to the representation of the issue, enabling identification of issues which are not problematised and policy solutions that have not been considered. The poor physical health of people with mental health disorders is attributed in policy to poor lifestyle habits and limited access to monitoring of physical health care. Three policy solutions are offered: collaborative care delivery involving greater use of fee‐for‐service primary care to manage physical health; the monitoring of physical health status by mental health teams; and the promotion of lifestyle change. These solutions fail to address ongoing issues with collaboration between specialist mental health and primary care services. Reliance upon fee‐for‐service primary mental health care may, in fact, reduce rather than increase access to services. The strategies are discussed in light of neoliberal ideals of governance and personhood which are underpinned by informed consumer choice and personal responsibility for health.     

Defining Community Care: realities and myths

This article looks critically at the concept of community care and argues that it is unhelpful and redundant. It makes three main points: first, that many care settings have elements of institutional and so-called community care and that there is no clear dichotomy between the two. Second, it is argued that the real distinction is not between the institution and the community but is between the institution and home. Community care is not provided by anonymous, altruistic others but comes from specific individuals (usually women) in domiciliary settings. The concept and definition of “home” are briefly discussed and it is suggested that most care is delivered either in a home , from home or at home. The third argument is that careful individual assessment is required to ensure that dependent people are not offered housing or residential solutions when what they need (and want) is care and services.     

Weaving nets: Housing and leadership in two Italian cities

As part of local welfare in Italy, housing policies underwent reforms that emphasized the role of local governments—and cities in particular—in the definition of the problem and in the elaboration of possible solutions. Housing is quite neglected in the political debate, but it is increasingly important for responding to citizens' demands in times of economic crisis. This paper reconstructs the policy process in two Italian cities, Turin (1997–2011) and Florence (1995–2011). The paper argues that policy change in housing can be fostered by a local political leadership that invests ideational, relational, and positional resources in policy making to spread new ideas, build networks of public and private actors at the local level, and attract fiscal resources while taking advantage of windows of opportunity at different institutional levels. Moreover, collaboration with local bureaucratic leadership proves fundamental to promoting innovative policies.     

The Effects of Housing Costs on Nursing Home Diversion

Abstract

This article examines the effect of the housing market on nursing home diversion and/or transition. Prior evaluations of federally funded diversion/transition efforts indicate that lack of housing may be a significant impediment to diversion policy efforts. We test this charge by examining the transition rates in all 351 municipalities in Massachusetts, using a data set of over 15,000 individuals seeking to remain or transition home between 2010 and 2014 through Massachusetts' Options Counseling program and their relation to key indicators of housing quality and affordability, including housing burden, crowding, and incomplete kitchen and plumbing facilities. We also control for demographic indicators identified in previous findings, which are age, level of frailty, and whether seniors live alone. We do not find a significant relationship between housing affordability or quality and successful nursing home diversion. This fact suggests that consumers are not as sensitive to housing costs and conditions as previously expected. Future research should continue to investigate the economic and social conditions behind this fact in the context of home value appreciation, incidence of home ownership, and the ability of seniors to offset nursing home costs through accumulated home equity.     

Big Business in a Thin Market: Understanding the Privatization of Residential Care for Children and Youth in Sweden

This article analyzes the transformation of Swedish residential care for children from a regionally coordinated, public social service system into a thin, but highly profitable, national spot market in which large corporations have a growing presence. Marketization and privatization are theorized as complex processes, through which the institutional structure and logics of this small, but significant, social policy field changed profoundly. Using official documents, register data, media reports and existing research, three consecutive phases in the development of the children's home market are identified since the early 1980s. Change was driven on one hand by policies inspired by New Public Management, which shifted public authority horizontally to the private sector, and vertically to local authorities (funding) and to the state (regulation). On the other hand were the responses of local authorities and private actors to the changing incentives that policy shifts entailed. During the first two phases, both the proportion and size of for‐profit providers increased, and the model of family‐like care was replaced by a professional model. Cutting across the trend of privatization in the third phase was establishment of a parallel system of homes for unaccompanied refugee children – mostly in public ownership. Similarities with privatization in the English system of children's care homes are noted. By showing how the Swedish market for residential care has been created by policy and by actors’ responses to those reforms, the article provides a foundation for thinking through how the predictable, significant and well‐documented problems of such care markets might be addressed.     

Housing policy and asset building: exploring the role of home ownership in East Asian social policy

Western societies promote home ownership in the belief that it provides a means to build up individual welfare and security, potentially offsetting the inadequacy of social security to meet needs in retirement. Some East Asian economies have long focused on advancing ‘asset building’ through housing policy. These efforts have two purposes: to use housing investment to drive economic development and to build family assets throughout life as a component of income protection for old age. These purposes work well in some countries but not as well in others. In policy terms, the common element among them is that governments promote home ownership as a component of social policy or as a complement to mainstream welfare. This article examines how home ownership fares as a form of asset-based welfare in selected East Asian countries (Singapore, Hong Kong and Japan) and considers the implications for understanding the role of institutions in development.