Prioritising Care Services: Do the Oldest Users Lose Out?

Population ageing is a major concern in most European countries. With an ageing population, people at employable age will have to provide for an increasing number of pensioners. Demands for health and care services will also increase, as older people typically have higher needs for such services. Such concerns are high on the political agenda in most European countries. What is often overlooked, however, is that older users increasingly compete with younger users over the same limited care resources. This is certainly the case in Norway, where responsibilities for care services have gradually been transferred to the local level over the past 20 years, with no national guidelines on the distribution of resources between groups of users.

In our recent article “Prioritising care services: Do the oldest users lose out?” (published in International Journal of Social Welfare, DOI 10.1111/ijsw.12116), we investigate the following  research question: What are the principles for the allocation of resources to older and younger users of municipal care services in Norway, and do these principles lead to equal or unequal treatment? The analysis is based on interviews with top level leaders in five Norwegian municipalities, as well as leaders of the service units, with an emphasis on how they prioritise and allocate care services to older and younger people in need of care. The interviews were undertaken in 2012. “Young users” in this context refers to all users under 67 years; be it with developmental disabilities, with severe physical injuries and illnesses, with mental illness, or substance dependency.

The informants express that they are forced into taking tough decisions regarding whose needs they should recognize and prioritize. When resources are scarce and there is need for prioritization, services to the elderly typically suffer. This tendency is confirmed in register data, which show that while there has been a substantial increase in overall resources in home care services over the last 20 years, the resources allocated to the elderly have actually decreased.

How do municipal workers justify these priorities? The guiding principle of municipal care services is that all users should receive services according to their need. The social construction of “need” thus comes across as a crucial issue. What do people need at various stages of life? Needs in this context do not refer solely, or even mainly, to physical needs, but also to the need for personal hygiene and general cleanliness, social contact, and everyday life skills. Employees in the home care services tended to downplay elderly users’ need for social contact and for help to better manage their everyday life. One striking example was how young users with mental disabilities would typically be allocated time to cook a meal with the help of a service worker, while elderly users would be fed a ready-meal.

We have suggested two main underlying arguments for this discrepancy in service allocation. First, an important ambition of the services was that users should be helped to live “a normal life”. For young users, this meant a life of education and (sheltered) employment, friendships and social activities – an active life. For users over 80, a normal life was assumed to be one of rest, peace, and limited social contact. The stereotype of the weary, passive old person thus tended to permeate the services, to the extent that it guided service allocation. At the same time, however, employees often express concern over loneliness among the old.

The second main argument stems from the “activation”-discourse, which is important in social policy in Norway. “Activation” is the main aim of employment services, where the aim is to increase users’ skills and employability and also to overcome any health-related barriers to employment. The aim of activation is to qualify and empower users to decrease their need for welfare state services. When this logic is applied to the care services, it makes sense to target in particular the young users: cook with a young man with mental disabilities today, and he may be able to cook without assistance tomorrow. This approach offers little to the oldest users: presumably those users have little time left, thus it makes little sense to invest time and energy in increasing their independence “tomorrow”..

These principles for service allocation are largely implicit, and obviously raise a number of normative issues. Is it reasonable to assume that frail elderly people do not aspire to an active life, and that they have little interest in making new friends or acquiring new skills at their latest stage in life? How can the voices of the frail elderly themselves be heard in this discussion? And should the activation argument be extended to care services for the most vulnerable members of society, or would this mean applying logic from employment services in an area of the welfare state where it really does not belong? In any case, our main argument is that the implicit assumptions currently underlying service allocations should be made explicit, verbalised, scrutinised and openly discussed. These discussions should not be left to service providers, but need to be addressed by politicians and policy makers.

This post has been jointly written by Anne Skevik Grødem and Heidi Gautun, Research Director at the Department of Health and Welfare Services, NOVA, Oslo and Akershus University College of Applied Science, Oslo.

 

 

 


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