Formal and informal care for older people: an example of ‘reverse crowding out’?

I’ve been working on a literature review of older people and social isolation, which has necessarily involved tracing the history of some of the ways that societies support older people. All sorts of approaches lie scattered about – from almshouses through residential care homes, home help and sheltered housing, from community care and home-sharing to contemporary favourites like co-housing and age-friendly places. Are we building towards the optimum combination, or just working our way through a finite range of politically salient options?

Let’s see what’s been happening in Sweden, a country known for its commitment to welfare in general. In a recent interview for the European Urban Knowledge Network, researcher Cecilia Henning observed:

‘What is interesting in the Swedish example is that we have had a very decisive policy towards ageing in place, but we have found that we have gone too far… we have closed a lot of residential facilities… because the politicians and the municipalities think that we should not have so much residential care, we should have ageing in place. So instead, we give home care in people’s homes. But at a certain point old people want to go to residential care units because they feel insecure and lonely.’

This seems to suggest that informal care provided in the home to older people in the interests of ageing in place has ‘crowded out’ the state’s provision of residential facilities. In a conference paper Henning and her co-researcher Magnus Jegermalm report that

‘After cutbacks and changed priorities concerning Home Help the public sector have focused more on helping people with ‘heavier’ tasks involving personal care (e.g. dressing, bathing, feeding, using the toilet). This development have most likely led to that informal caregivers and volunteers commonly carries out ‘lighter’ tasks for someone who is a relative but might also be a neighbour or a friend.’

Hmmm. This appears to be an example of ‘reverse crowding out,’ whereby ‘private provision of a public good replaces existing tax-supported provision of the public good' (Isaac and Norton, 2013). Just what the neo-liberal ordered? (Although to be realistic for a moment - not an attitude that can necessarily be associated with neo-liberals - there doesn't seem to be very much research that supports the crowding out hypothesis in the welfare context).

What is clear is that the current ‘in-vogue’ approach, ageing in place, is, like all other approaches to support for older people, inescapably political.