JOURNAL ISSUE 12
University of Augsburg, Germany
Dorit Sing, PhD (PolSc)
The influence of economy on social work in the field of care of older people: Possibilities of advocacy and empowerment in social work policy-making
Virtually no sector of the welfare state is as closely connected to the economy as the care for the elderly. Firstly, this is due to the fact that it uses – or has to rely on – complicated, expensive and sophisticated services of the health care system, especially in the field of chronic diseases. Secondly, this is due to the fact that it has to offer a broad scope of services which by far exceed the traditional frame of welfare interventions. Lastly, this is due to the fact that it has to serve a continuously increasing number of clients. Major factors in this process are the different ‘codes’ of social work and economy. In this article it will be shown, on the basis of the care for the elderly in Germany, that it is necessary – and possible – for two ‘social systems’ (in the sense of Niklas Luhmann 1987) with very different ‘substantial interests’ to build up new ‘intersystemic interests’: it is necessary for the sake of the elderly, and it is possible, if economy as well as social work are to be able to overcome the status quo of a narrow-minded maintenance of obsolete prejudices.
Keywords: care for the elderly, case management, ‘person-bound care budget’, social work
Elderly people are concerned about social exclusion in very different ways. In this situation, to become in need of care and attention is an additional risk factor for people who are already disadvantaged by other phenomena of social exclusion (e.g. low income). Thus comprehensive care arrangements are able to prevent or overcome exclusionary processes and to increase the chances for people to have a self-determinated life in old age.
Virtually no sector of the welfare state is as closely connected to the economy as the care of the elderly. Firstly, this is due to the fact that it uses – or has to rely on – complicated, expensive and sophisticated services of the health care system, especially in the field of chronic diseases. It is also due to the fact that it has to offer a broad scope of services which by far exceed the traditional frame of welfare interventions. Lastly, this is due to the fact that it has to serve a continuously increasing number of clients. Dementia related to old age and Parkinson’s disease are only two of a number of examples which may serve to illustrate the new challenges which are emerging in these sectors of the welfare regimes.
Care for the elderly has entered into a highly modern, and in part in a highly technical, sector of the health care system within the space of a few decades. In particular in the field of nursing, the religious roots of social work and the consequent religion-based motivations of social workers often conflict with the requirements of modern ‘social technology’. Major factors in this process are the different ‘codes’ of social work and economy. In this article it will be shown, on the basis of the care provided for the elderly in Germany, that it is necessary – and possible – for two ‘social systems’ (in the sense of Niklas Luhmann 198)) with very different ‘substantial interests’ to build up new ‘intersystemic interests’ (see Schimank 1992): it is necessary for the sake of the elderly people, and it is possible, if the economy as well as social work are to be able to overcome the status quo of a narrow-minded maintenance of obsolete prejudices.
Firstly a short overview of the relationship between economy and social work will be presented. It will become clear that because of the difficulties in the public budgets there has been a demand for increased effectivity and efficiency. The new notion of ‘customer’ (Kunde) rather than ‘client’, as well as the measuring of effectivity and efficiency of social work, seem to be in contradiction with the professional self-understanding of social workers, especially concerning their understanding of professional quality. Using the introduction of person-bound budgets for care (PBBs) in connection with case management in a model project in Germany, it will be shown that it is possible on this basis to satisfy the economic aspects of reduction in costs and at the same time to secure a better quality of care for those people who are in need of care and attention.
Social work effectivity and efficiency: A German perspective
In the past, social work in Germany has been subject to many different influences, including political and therapeutic influences, etc. These were not only temporary but also resulted in processes leading to profound changes in the field of social work (see Meinhold 2003, p. 130 ff.). Due to the increasing importance of economic concepts and analytical tools, social work is currently forced to face a broadening of its scope and perspectives. On the one hand, this leads some observers of the field to underline the risks of this process: they warn that the ‘super-power’ economy might undermine the self-image, self-esteem and aims of social work and its actions. In contrast, others emphasize the opportunities of an economic approach towards social work: by evaluating and proving its effectivity and efficiency the profession and its status in society might be legitimized and increased (see Meinhold 2003).
New governance of local authorities: Social workers as service providers
The reason and background for this development of an ‘economization of social work’ in Germany is mainly based on the increasing problems of financing the services of social work. Since the 1970s, continuously rising rates of unemployment and the financial costs of the German reunification have led to decreasing income from tax, which in turn has resulted in a decrease in financial resources. This situation is enhanced by the fact that since 1990 there have been transfer payments from West to East Germany. As a result, local budgets are under continuous pressure to save financial resources. Hence, an increase in the effectivity and efficiency of civil services has to be achieved under conditions of economic restraint.
While these tendencies are internationally discussed under the terms of ‘new public management’, the slogan in German discussion is Neues Steuerungsmodell der Kommunalen Gemeinschaftsstelle für Verwaltungsvereinfachung (KGSt) (see Wollmann 1996). The new ‘Leitbild’ or motif of this new governance model is the service enterprise. In principle, it should serve as a model for reconstructing the administration from intervention authority to service supplier. This transformation process is to be accomplished by transferring business management mechanisms from the private to the public sector (see Schaarschuch 2003, p. 151 ff.).
Two levels can be differentiated:
At an organizational and institutional level these aims should be achieved by the tools of contract management, budgeting, combining of the professional specific responsibility and resources responsibility, service or output orientation, and implementation of controlling and quality management measures.
At the level of the concrete service action, i.e. the interaction of the local administration officers (or social workers), it is aimed to form this according to the service model. This means that the action is no longer oriented towards the passive ‘client’, but towards the wishes and needs of the so-called ‘customer’.
The hypothesis states that this orientation towards the customer, or consumerist model, helps to optimize the balance between supply and demand and leads to an increase in effectivity and efficiency of social services.
Antagonism between the self-image of social work and the ‘economization’ of social work
The use of a consumer model and the increasing importance of the effectivity and efficiency aspects have been challenged and argued by several professionals in the field of social work, both in public service and the care sector. However, there are also supporters of this new development. Contradictions between the self-image of social work and the ‘economization’ of social work are listed as follows:
The consumer model is looked upon as not being adapted to reflect reality as far as the client or consumer is concerned.
Aspects such as increasing effectivity and efficiency of social work are often suspected of leading to rationalization, including reductions in staffing levels and the numbers of social workers.
Researchers in the field of social work underline the fact that there is no objective measurement of the quality of social work. Certification and accreditation does not measure the quality of social work (product quality), only the correct documentation of quality assurance (process and documentation quality) (see Meinhold 2003, p. 143).
It is taken for granted that social work and economy are two systems with contradictory and exclusive logics. This implies that due to this antagonism of their different logics they might not be able to solve the problems of modern society, e.g. by providing adequate care for disadvantaged groups of society. In the following it will be shown, on the basis of the care for the elderly in Germany, that it is necessary and also possible for two ‘social systems’ (in the sense of Luhmann 1987) with very different ‘substantial interests’ to build new ‘inter-systemic’ interests in order to address the new challenges of social work (see Schimank 1992).
New ‘inter-systemic’ interests in the care of the elderly
The construction and improvement of social security systems is a continuous and ongoing task in the whole of Europe. The most recent challenge of social policy has been to identify those at risk of needing care. Although people needing care have always existed and for centuries elderly and weak people have been taken care of by their relatives or by charitable institutions, it is only in recent decades that the need for care as social risk has become a central issue of welfare state social policy – historically, after social risks such as morbidity, age, invalidity, or joblessness, which have at least been met by social policy. The main reason for the need to construct a social security system for providing care is due to the fact that (in cases when care is needed) both the individuals needing care as well as their family and relatives are very soon overwhelmed by the many aspects of respectively needing or providing care.
The introduction of long-term care insurance in Germany in the 1990s has improved the situations of both those needing care and their relatives, mainly with regard to economic and financial support issues. However, other important aspects of social support, such as advice and help in the planning of domiciliary care have largely been neglected. Thus, people needing care and their relatives are still very often alone when they are confronted with the need to provide care.For instance, they have to choose the most suitable and fitting support systems out of a huge supply or warehouse of possible support services and strategies. They have to organize and finance those aspects and needs for care which are not paid for by long-term care insurance (especially regarding social integration). Moreover, several studies, such as the EC-funded research project Care for the Aged at Risk of Marginalization (CARMA), have shown significant disparities regarding the real use of different services and offers met by long-term care insurance: ‘The claims which are made for specific care insurance benefits show the clear influence of gender, social status, ethnicity and living conditions. This applies not only to the choice of the actual offers and the role of informal care within the family framework but also to the possibility of complementing care needs that are not covered by care insurance benefits with private means’ (Theobald 2004, p. 3). Theobald (2005, p. 38) concludes: ‘However, the unequal claims of different offers and benefits of the long-term care insurance, the neglect of social services and the difficulties of a fragmented infrastructure impede the establishment of an adequate care-arrangement especially for disadvantaged groups in society’.
Aging in general and also the changes in the age structure in our population, the medical and technical progress, and the tendencies of individualization and pluralism in our society, as well as the erosion of the family as an institution are increasing the social and economic pressure to find adequate solutions for the aforementioned issues. In the meantime, several other European countries have introduced long-term care insurance; others think about introducing long-term care insurance; and still others try to meet the need for care within existing social security systems which are, for instance, financed by taxes. Here, I am not trying to compare different European long-term care insurance systems, but to discuss a specific strategy to increase both effectivity and efficiency in the provision for people needing care, i.e. the introduction of the person-bound ‘care budget’ (PBB) together with case management.
Person-bound budgets (PBB) were partly introduced more than 10 years ago in some European countries, including the United Kingdom, the Netherlands and Sweden (see Arntz & Spermann 2004, p. 7). Although at present no evaluation studies regarding the efficiency of PBBs exist for these countries, there is some empirical evidence that a better quality of care can be achieved by PBBs. For instance, the degree of satisfaction of people in the need of care can be increased if they are able to actively take part in shaping their care arrangements within their PBB. In Germany, PBBs are currently an important issue in social policy planning. They are facilitated by health insurancewithin a frame of ‘integrated assistance’.Model projects based on PBBs have also been installed in the social work for disabled persons. These projects show the general need for such solution strategies. However, so far, no concrete efficiency analyses have been performed.
A current project on PBBs in seven centres in East and West Germany has been designed to obtain data regarding the efficiency of PBBs. By comparing randomized interventions and control groups in the period between 2004 and 2008, the social experiment ‘PBB’ will be evaluated with regard to its economic aspects. The project’s design has two interesting aspects. The first aspect is based on a speciality of the German long-term care insurance system which comprises benefits in cash and/or benefits in kind for the domiciliary and the residential care sector. The second aspect is the combination of PBBs with the advisory or counselling role of case management.
Introduction to PBBs and case management
The introduction of the PBB in combination with case management is expected to lead to improved cost efficiency. The PBBs should help to increase the time span of people in domiciliary care, thus avoiding an early transfer to expensive residential care (residential care costs in Germany can be as high as 4000 EUR per month). The social network tries to meet the needs of the person adequately. In cases of on-going deterioration in the person’s situation, however, these needs can no longer be taken care of by the domiciliary support system. This finally leads to hospitalization or transfer into residential care. Another typical form of ‘career’ of elderly people in the form of hospitalization often occurs due to an accident or a sudden acute event (crisis) (see Wissert 1999). After acute medical treatment is completed the person is discharged into a home for the elderly and into residential care. One reason for this is based on the fact that due to the increasingly shorter hospital stays (as a consequence of the policy if saving costs in the health system) the elderly person in need of care is not yet able to manage their daily life at home on their own. In order to avoid simultaneously paying for their own housing and residential care, the home ownership is ended and the person moves into a home for the elderly on a permanent basis. This is a ‘one way street’ into residential care and thereby the point of no return is reached.
The introduction of the PBB in combination with case management aims to interrupt these typical ‘careers’ and to postpone transfer into residential care for as long as possible. The aim of reducing costs is mainly achieved based on two factors: (i) the services of care insurance in the domiciliary sector are significantly cheaper than those in the residential sector; (ii) until now, in the case of inadequate private financing (for instance in the form of inadequate retirement pensions and the services of care insurance) the local authorities had to pay for the costs of the residential care by means of social benefit payments. These costs will be avoided in the future.
The introduction of the PBB in combination with case management mainly raises expectations regarding the improved cost-efficiency of care provided. Additionally, an improvement in the quality of care is expected. The project funders have the following concrete expectations and aims regarding the introduction of PBBs:
Flexibility of the service/output of long-term care insurance combined with better consideration of the wishes and needs of those in need of care, especially people with dementia.
Support for the autonomy of both those in need of care and their relatives, combined with a strengthening of their positions as ‘clients’.
Impulses for the further development of the infrastructure of domiciliary care.
Taken together, the PBB mainly aims at enabling longer periods of stay in domiciliary care in order to avoid costly residential care for as long as possible. In the future, therefore, the PBB could therefore help to secure a high quality standard of care at reduced costs.
The financing of the PBB
Initially the PBB project has to face higher costs, because the benefits are only allowed to be provided in kind (in general, the costs of providing benefits in kind are higher than the benefits paid in cash in the domiciliary care sector) and also because the PBB is combined with case management. Table 1 shows the type and amount of provision of long-term care insurance in the case of domiciliary care. The main types of domiciliary provision from long-term care insurance can be divided into those that are provided in cash and those provided in kind (see Holdenrieder 2003, p. 156 ff.). If a disabled elderly person chooses domiciliary care services in kind, the scheme provides for domiciliary visits (personal care and home-making assistance), e.g. by professional nursing staff. In this event, the benefit is directly paid to the organization providing the service. Monthly maximum amounts are set for the disabled elderly depending on their degree of disability.1
Table 1: Types and amount of provision of long-term care insurance in the case of domiciliary care.
Degree of disability
Benefits in kind
Benefits in cash
Care degree I
Care degree II
Care degree III
As an alternative to benefits in kind, the disabled elderly may receive domiciliary care benefits in cash, if they are able to secure adequate personal care and home-making assistance for themselves from informal care providers. Benefits in cash are lower in value than services in kind and payment is also dependent upon the level of disability.
The PBB is given in the height of the costs for benefits in kind and is higher than the cost of benefits in cash at every level of single care (Pflegestufe) in the domiciliary sector. The PBB is a benefit in cash which may be used by person in need of care and/or their relatives for the buying adequate care services. In the future, PBBs might supplement the existing domiciliary care benefits in kind and care benefits in cash in Germany as an additional way of financing the need for care, if the scheme is shown to be a cost efficient method in these ‘social experiments’.
The PBB is paid as benefit in cash, equivalent to the amount of benefit in kind for the respective level of care, to buy specific care services. Its novelty is based on the fact that in contrast to domiciliary care services in kind neither the care services nor their prices are static and fixed. This implies, however, that the PBB can no longer be used for paying relatives directly or to buy services on the black market, as might be the case with domiciliary care benefits in cash. Case managers are installed to ensure an adequate quality of care and to help the persons needing care to use their PBB adequately and reasonably. The case managers are expected to assess the actual need for care and support, consider the quality of care and help to achieve services regarding the individual wishes and needs of their clients.
The action approach of case management in combination with the PBB
The support and advisory management (Unterstützungsmanagement) is a form of counselling. Originally developed in the Anglo-American sphere, it was successfully introduced to Germany in the 1980s in different areas of social work, such as rehabilitation, family counselling, reintegration of delinquents, work with substance abusers, and work with disabled people or psychiatric patients. Case management helps to make the efficient use of financial resources more transparent and to identify and evaluate the effectivity and efficiency of social work interventions and actions. It also implicitly incorporates an altered understanding of social work (‘client orientation’) into its counselling concept. In the following some brief outlines of a possible model of the case management concept based on the work of Wissert will be shown (1999; 2005) (for the organization of case management in England see e.g. Shardlow & Adams 2005, p. 151 ff.; for an example of case management in Norway see Zahl 1999/2000).
Case management in the event of the need for care
A key task of case management is to find out what kind of care is needed at what point in time and to what degree. Moreover, the case manager has to know which agencies offer what kind of support. As result of the case management, good quality care arrangements are expected which have to be flexible in order to make ambulatory care last as long as possible. Case management is client-oriented, i.e. the specific situation is decisive for planning and implementing the care process, but not the range of services offered by the care supplier/institution. Therefore, a change in the counselling strategy is needed. Social work may no longer just counsel and be active separately only at the ‘interfaces’ of the residential and domiciliary care system, but has to form part of a long-term integrated and stable care plan which helps those in need of care to postpone their entry into residential care for as long as possible.
Figure 1: The counselling strategy of case management.
Source: Wissert 2005.
The PBB in combination with case management connects comprehensive care planning, organization and integration with the identification of costs, expenditure of time and efficiency of social work. In this sense, counselling follows a floating scheme involving several steps with clearly separated processes (see Wissert 1999, p. 141 ff.). In the initial phase the case manageridentifies whether the client wishes to accept counselling and whether the case manager is suited to help solve the client’s problems. If both the case manager and the person in need agree on these two issues, a contract between the case manager and person in need (or a relative) regarding the start of the assessment process is implemented.
The assessment helps to identify the actual problems of the person in need of care and also considers the client’s resources as well as their social context. The case manager outlines an idealized plan of the best care service options possible according to the time and financial resources of the person in need, the personal competences and deficits of the client, and the institutional infrastructure and service offers available. It is of central importance that this is done as an interactive ‘negotiation’ process (see Oevermann 1996), allowing for a participatory decision process on the part of the client (‘shared decision-making’). Only if the client’s compliance is guaranteed, a high level of effectivity and therefore efficiency of the planned measures can be reached.2
If the case manager and client agree on the idealized plan a contract will be outlined based on the actual concrete care plan as well as on the intended aims of the care plan. Based on the concrete care plan, the case manager will organize and coordinate support and care services. The case manager is responsible for the correct financing of the care services. Lastly, the care manager coordinates, controls and evaluates the care givers and also the care services provided in close cooperation with, and with feed-back from, the client. A major problem in this regard is posed by the fact that no sufficient indicators for measuring the quality of care services or satisfactory outcome measures exist at present in Germany (e.g. at what point or by what definition a care service is considered successful; see e.g. Merchel 2003).
The counselling process ends when the intended aims of the care plan have been achieved. The client and case manager cooperate in evaluating whether the contract has been fulfilled and what the outcomes are. After this preliminary evaluation the contract is ended.
Some key functions and evaluation of the outcomes of case management within the concept of the PBB
In this process, the case manager is not a direct care giver or service supplier, but rather plans, coordinates and arranges the support needed and care services to be provided. The case management works along a concrete and written care plan agreed upon by both the case manager and the client. This is an important difference compared to existing traditional approaches based on the situative and individual competence of counsellors.
A counsellor in a case management process can accomplish some important functions. He/she fulfils a broker-function, i.e. mediates services and support as needed by the client. Another function is gate-keeping.The case manager coordinates and organizes the access to services and their suppliers as well as controlling the rational use of financial and other resources. Central issues are the advocacy- and empowerment-functions. Advocacy-function is often associated with or has connotations of paternalism. In this context, however, it means to support the person in need of care in such a way that they are able to make their own decisions (see above). To achieve this goal, the advocate or counsellor has to be independent from a service supplier. Furthermore, as adapted from the South-American liberation philosophy, empowerment-function means to mediate abilities, resources, self-esteem, and authority to persons who are otherwise lacking these. Translated into the care process, this means that people in need of care are given the possibility to develop their own plans and strategies for action within the care process.
Persons in need of care (or their relatives) are clients of a social service which is offered by the case manager. The right of self-determination and the autonomy of the client are central issues in this process. The client and their social context are involved in this process. Own resources, established and existing social networks, coping strategies, wishes and interests, as well as possible interferences and obstacles all have to be considered in the planning of care. By continuously informing the client, the care process will become transparent from the very beginning, thus enabling the client to participate in the care process and to guarantee her/his autonomy and individual rights. In addition to an evaluation of the care givers as well as the care services by both the case manager and the client, an additional evaluation of the outcomes of the case management is needed. In one or more meetings which are separated both in time and structurally from the counselling or case management process, both case manager and client evaluate the middle-term effects of the care process. The case manager documents the complete case management care process in written form.
Effectivity and efficiency of case management in the care sector
Social work is obliged to prove its effectivity and efficiency in times of scarce financial resources. Case management offers an opportunity to achieve this goal by evaluating the effectivity and adequate use of these resources. Yet it also incorporates an altered understanding of social work (‘client orientation’) into its counselling concept. In conclusion, the highest possible acceptance of the planned care service strategies will be accomplished. The results of research on compliance show an improved quality outcome of social work as well as positive economic effects if clients are integrated and participate in care processes as outlined above. Moreover, the potential for self-help is fostered by the dynamic character of this kind of care process. Concepts of counselling in the field of care for elderly people so far only consider some partial aspects of the issues outlined above. Currently, people in need of care receive counselling – if at all – from many different agents and institutions which offer different ranges of services. Consequently, only those care services which are offered by the respective institution are available, while others are not considered or included at all. Additionally, a reasonable coordination of care services and care givers is often lacking.
The case manager offers a method which – at least in the case of its early implementation into the ‘care-needing career’ – might help to postpone the need for transfer into residential care and resulting social exclusion processes for as long as possible. The PBB in combination with case management might therefore very well act as a preventive measure. The success of this concept might lead to cost efficiency. However, as experiences from other countries have shown, the aim primarily – or even exclusively – for cost efficiency should be avoided when considering implementation of the PBB and the concept of case management.
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1 The degree of the need of care is determined by the medical service of the health insurance funds. This is done on the basis of rigid standardized criteria which are frequently criticized.
2 In studies from Anglo-American countries it has been shown that ‘shared decision making’ has positive effects on compliance, treatment success and client satisfaction. The concept of shared desision making is currently used and evaluated in several research projects of the German health system (Bundesministerium für Gesundheit 2006).
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