Abstract

Objectives: We take on the ancient and ongoing debate about the relationship between LTC and informal care, mostly family. Are they interdependent, that is, where one goes in, the other goes out or is “crowded out”, akin to substitution effects? They may also supplement each other, or even have “crowding-in” effects. With dramatic growth, and then big cutbacks, in her public services and no family obligations, Sweden offers a field experiment of the balance between the state and the family.

Methods: With use population studies of older persons to scrutinise needs for care and patterns of support from 1954 to 2009. We examine family care and various types of public services, and whether needy persons use only either kind, or both. We can then assess hypotheses about substitution effects, and whether care is “restored” to families or not.

Results: Relative to needs, both family care and public services (Home Help) has remained stable. There has been an increase in informal care overall, partly in response to rationing of public services, partly because older people today more often are partnered and much more often have children. Importantly, the life-time chance to receive public services has increased sharply over time, notwithstanding lower cross-sectional user rates. A visible effect is the increased overlap of informal care and public services in contemporary Sweden.

Conclusions: The frontier between the state and the family has shifted slightly, but families stay involved. The division of responsibility between the state and the family is always in flux, and a matter of the perspective chosen. This is particularly visible with the time perspective used here, covering a period with greatly improved social security and health, better housing and services for older people, and shifts in attitudes and preferences. Yet, the major pattern that emerges is that of a relatively stable balance of care between the state and the family, including possible other actors outside the public domain.

A robust finding is the increasing overlap of family care and public services, as more older persons are cared for in the community, and more of them have a family. Services are assumed, according to law, to address both the older person and the families. This has proved to be difficult, where some caregivers have to reduce, or adjust their working hours or leave work altogether. Ageing-in-place policies with drastic reductions of institutional care has shaken Swedes’ idea of a “social contract”, with high taxes exchanged for generous public services from “cradle to grave”.