Public and private nursing homes in Norway and Sweden: what do we know about ownership and quality?

Conference May 14, 2014, Bergen.

Marta Szebehely

Professor of Social Work

Stockholm University

marta.szebehely@socarb.su.se

• Presentation based on work carried out within Normacare

• New report: Marketisation in Nordic eldercare

• Contributions by 17 scholars from 7 countries

• Download or purchase (125 SEK): www.normacare.net

Marketisation in a Nordic context of universalism

• 1980: Publicly funded and provided services for all; some non-profit; no for-profit – a trust based system; very little regulation and control

• 1990: importation of market ideas – ”competition will improve quality and cut costs”

• Based on economic theory, ideology and economic interests – rather than on older people’s demands

• Today: – Sweden: 18% for-profit; 3% non-profit– Norway: 4% for-profit; 5% non-profit

• Large municipal variation

Much larger for-profit sector in Sweden (and Finland) than in Norway (and Denmark)

• Timing matters (recession)? Resistance matters?

• Competetive tendering favours large corporations

• Sweden: ½ of private nursing homes (10% of all ‘beds’) run by the two largest corporations (Attendo and Carema), owned by private equity companies, each with 15,000 employees in the Nordic countries

• Higher concentration than in most countries – an attractive market

• Large actors have loud voices – affect policy makers

Consequences of marketisation – what is known about quality?• Structure : Lower staffing, lower training and fewer

permanently employed in for-profit – lowest in largest corporations

• Process: For-profit report more assessment of risk for falls, pressure ulcers et – most in largest corporations

• Outcomes: – No data on actual falls, pressure ulcers etc– No difference in ’user satisfaction’.

• Unintended (?) outcomes: Stricter regulation & control

Consequences of marketisation: contested issues

• Economists:– Competition higher efficiency: better process quality and

equally satisfied users with fewer resources– Improved quality by user choice in homecare and by

better tenders and stricter control in nursing homes

• Care researchers: – Time, continuity and flexibility crucial for users High

staffing ratios and permament employment important quality indicators

– Stricter regulation and control negatively affect flexibility– Care services not like other services– Users to frail to act as customers

Consequences for universalism: the distribution of welfare

• Very little Nordic research• Non-profit actors need protection• Winners and losers in choice models?• Increased private financing (topping up)?• A threat to universalism?• Rebecca Blank: ”The more one cares about

enforcing universalism in the provision of services, the stronger the argument for government provision”

Thanks for listening!