Marta Szebehely Professor of Social Work Stockholm University marta.szebehely@socarb.su.se

1. 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

2. 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

3. Marketisation in a Nordic contextof universalism • 1980: Publiclyfunded and provided services for all; some non-profit; no for-profit – a trust based system; verylittleregulation and control • 1990: importationof market ideas – ”competitionwillimprovequality and cutcosts” • Based on economictheory, ideology and economic interests – ratherthan on olderpeople’sdemands • Today: • Sweden: 18% for-profit; 3% non-profit • Norway: 4% for-profit; 5% non-profit • Large municipal variation

4. Muchlarger for-profit sector in Sweden (and Finland) than in Norway(and Denmark) • Timing matters (recession)? Resistancematters? • Competetive tendering favourslargecorporations • Sweden: ½ of private nursing homes (10% of all ‘beds’) run by the two largest corporations (Attendoand 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

5. Consequences of marketisation – what is known about quality? • Structure: Lowerstaffing, lowertraining and fewerpermanentlyemployed in for-profit – lowest in largestcorporations • Process: For-profit reportmoreassessmentof risk for falls, pressureulcers et – most in largestcorporations • Outcomes: • No data on actual falls, pressureulcersetc • No difference in ’usersatisfaction’. • Unintended (?) outcomes: Stricterregulation & control

6. Consequencesofmarketisation: contestedissues • Economists: • Competition higherefficiency: better process qualityand equallysatisfieduserswithfewerresources • Improvedquality by user choice in homecare and by better tenders and strictercontrol in nursinghomes • Care researchers: • Time, continuity and flexibilitycrucial for usersHighstaffingratios and permamentemploymentimportantqualityindicators • Stricterregulation and controlnegativelyaffectflexibility • Care services not like otherservices • Userstofrailtoact as customers

7. Consequences for universalism: the distribution of welfare Verylittle Nordic research Non-profit actorsneedprotection Winners and losers in choice models? Increased private financing(toppingup)? A threatto universalism? Rebecca Blank: ”The moreonecaresaboutenforcing universalism in the provision of services, the stronger the argument for government provision”

8. Thanks for listening!