1. Introduction

The current ageing process represents a challenge for European societies to adapt their welfare models to the needs of a growing elderly population that requires new care services. Although recent advances in modern medicine and the development of welfare models have benefited a large part of the society (Del Barrio et al, 2021), population ageing entails new and increasing demands for long-term care (LTC) services and makes it urgent to redefine the current models of provision of elderly care.

Home-based care services for elderly dependent adults. A comparative analysis of Madrid and Stockholm.[1]

This need is progressively being recognized in the European Union’s political agenda. A fundamental step taken in this regard was the approval of the European Pillar of Social Rights which recognized that "all people have the right to long-term care" (European Commission, 2017). The COVID-19 pandemic undoubtedly had a significant and positive impact on this consideration of care as a fundamental element for the sustainability of lives, as the feminist movement has been pointing out for decades (Daly and Lewis, 2000; Federici, 2012; Tronto, 2015). This impact became evident in the recently approved European Care Strategy, which highlights the need to carry out far-reaching political reforms in this field. The strategy urges member states to guarantee "the principles of equality, freedom of choice, the right to independent living, and prohibition of all forms of segregation for persons with long-term care needs''. At the same time, it targets to the precarious working conditions of workers in this sector as a structural problem that also needs to be resolved (European Commission, 2022).

Beyond the increasing care needs, population ageing has also brought about a new vision of old age that advocates for elderly rights and promotes the principle of “ageing in place”, understood as a process to build environments that respond to the needs and individual aspirations of the elderly (Buffel, Phillipson and Scharf, 2012; Fundación La Caixa, 2021). This principle helps to bring to the forefront the underlying structures that lead to discrimination against the elderly (World Health Organization, 2021) and, therefore, confront the prevalent concept of ‘ageism’. In this line of changes, associations and international organisations are advocating for personalised and community-based services, putting people at the centre and making an assemblage of diverse institutional actors and resources led by governmental agents (Schuurmans et al., 2020).

Based on the idea of building community, this article explores the home care service (HCS) in two different contexts, Madrid and Stockholm, analysing key actors’ perceptions towards necessary reforms. Both Spain and Sweden show similar levels of population ageing (20.1% of the population is over 65 in Spain and 20.3% in Sweden), although the process is more acute in the Spanish capital of Madrid (20%) than in Stockholm (16%) (Eurostat, 2022). Demographic projections estimate that these percentages will increase in the coming decades in both countries, although more sharply in the case of Spain (32.7% in 2050, with 23.5% in Sweden) (European Commission (b), 2021). From a gender perspective, women account for 61% of the population over 65 in Madrid (Spanish National Statistics Institute, 2023), and 54% in Stockholm (Statistics Sweden 2023), which points to the phenomenon of the “feminisation of old age” and the need to incorporate this perspective in analysing elderly care. In addition to living longer, women suffer from poorer health conditions, which together with their lower income and higher likelihood of living alone, put them in a situation of greater demand for LTC services (European Commission (a), 2021). Feminisation is also present in the composition of the care workforce, where women account for the majority in a sector that faces precarious working conditions (ILO, 2018).

Understanding that it is necessary to adapt LTC services to improve both provision and labour conditions of the sector, this paper explores the key characteristics and recent developments of HCS in order to detect needed reforms to extend elderly support under conditions of autonomy. The paper is divided into four sections, the first one being a general approach to HCS in both geographical contexts, while the second explains the methodology. The third section presents the results and is divided into three subsections that summarise the three main analytical fields. The last section offers some conclusions and reflections for discussion and debate.

2. Contextualising the Home Care Service in Madrid and Stockholm

Although Madrid and Stockholm belong to different welfare models and have diverse traditions providing elderly care services, they share the common challenge of redefining home care service in a context of increasing needs. In Spain, the development of social services during the first decades of democracy led to a significant increase in home care services - managed at that time by municipalities - in the 1990s (Marbán, 2019). However, the subjective right to care provision was not formally included in national legislation until 2006 with Law 39/2006 on the Promotion of Personal Autonomy and Care for Dependent Persons (LAPAD from now on). Although the right to care is recognised at the national level, there are significant inequalities across regions, and discussions around governance issues, financial sustainability and the question of equality in the access to services dominate public debates (Rodríguez Cabrero and Marbán, 2022). The Swedish case falls under the universalistic welfare model, in effect since the mid-20th century, with equality as a core value and the understanding that services should be affordable for the poor and attractive enough to be preferred by the middle class (Szebehely & Trydegård, 2012). According to the Swedish Social Services Act of 1982, all older people have a general right to help and support according to each person's specific care needs. In recent years, the concept of "free choice" has been regulated to ensure that older people are able to choose their HCS from a list of approved providers (Brodin and Peterson, 2023). The Act on System of Choice (LOV) from 2009 establishes the conditions that apply when a municipality decides to implement choice.

In terms of coverage, 9.33% of the population over 65 received home-care service in Madrid in December 2022 (Imserso), while in Stockholm 11.9% did so in 2023 (excluding those persons with only alarm service, meal distribution, carer relief, or accompaniment service outside the home) (Sweden Statistics). In terms of intensity, Madrid offers 17.68 hours/month (Imserso), with Stockholm at 40.8 hours/month (Sweden Statistics)^[2].

In sum, both cities are at different stages of development of HCS and face dissimilar problems. At the same time, they are both under pressure to offer quality services to a growing population group.

Madrid

In Spain, HCS was included in the catalogue of services entailed in the Dependency Act with the explicit intention of expanding it to promote the principle of ageing-in-place. In the case of Madrid, HCS is regulated through a multilevel governance system, that has been described as complex and unclear (Rodríguez Cabrero y Marbán, 2022), as it assigns responsibilities to both the regional and municipal government. Regional governments (LAPAD framework) are responsible for carrying out the assessment of needs, based on which an Individual Care Plan is approved. This plan specifies the number of hours of HCS and establishes links with other possible social services. The municipalities also offer HCS to people that are not covered by regional governments but who require some type of support to perform daily tasks^[3]. ‘Municipal HCS’ and the ‘LAPAD HCS’ are often incompatible and mutually exclusive, but in practical terms it is the municipality of Madrid that manages both services by virtue of a "collaboration agreement" between the two institutions (regional government and municipality). The management of HCS service is fully outsourced in Madrid and it is organised top to bottom in three very large lots allocated to three companies that assisted 81,923 people (2023). Hence, an older person is assigned one professional from a private company that manages his or her district. The “freedom of choice” principle is not integrated into the regulatory framework, although recent policy documents are starting to include this concept in the definition of the new model for care provision, in line with the European Care Strategy (Ministerio de Derechos Sociales y Agenda 2030, 2024).

Stockholm

In the municipality of Stockholm, HCS is regulated at two levels: at the municipal level (the city council) and the city district level. The city council formulates and adopts the city’s eldercare policies, such as market entry requirements for care providers, reimbursement levels for care providers, and guidelines for needs assessment. The 13 city districts are responsible for needs assessment and continuous monitoring of providers. Once a decision has been made and the older person has chosen a provider, the care is planned and provided in accordance with the time allocated to the services. Care managers often use a time template to determine the amount of time the older person will receive assistance per day or per week (e.g. 15 minutes three times a day for assistance in going to the toilet). The care provider must draw up a care plan together with the older persons in their homes and the plan should be available digitally in the care workers’ mobile phones. Then, the delivery of care is organised on the basis of a time framework, the total monthly time granted, with the aim of giving care recipients and care workers some flexibility to make decisions in daily interaction.

The municipality introduced freedom of choice in HCS back in 2002. Since then, marketisation has been stronger in Stockholm than in other municipalities and regions of Sweden. The management of HCS is partially outsourced: in addition to the public HCS, there are 30-50 different home care companies that users can choose from in each city district. In total, 18,692 users are assisted (2023). In order to limit the number of providers, strengthen the municipality’s control and improve quality, stricter market entry requirements for private care providers were introduced in 2018. Providers are reimbursed based on a digital time register performed by the care workers. Home care companies are also allowed to offer additional domestic services. Such out-of-pocket services are not needs assessed, but are tax-deductible.

3. Methods and research design

The analysis draws on qualitative semi-structured interviews with key informants. In Madrid, 11 interviews were carried out between October 2022 and October 2023, and in Stockholm, 18 interviews were conducted between 2017 and May 2018^[4]. In both cases a purposive selection was used, meaning that the informants included were considered to be key actors in the field as they were engaged in issues related to home care for older people. The majority of the informants were institutional actors involved in implementation or policymaking, while others were engaged in advocacy (representing the interests of care workers or the elderly). Given their roles and positions, it was expected that these informants could provide insightful and relevant accounts of the changes and challenges of home care in the two cities.

In the case of Madrid, the informants included five officials who held positions of responsibility in elderly care design and implementation at different levels of the municipality; three representatives from labour union organisations that advocate for workers’ labour conditions (CC.OO, UGT and Unión Colectivos Estatales SAD); one member of the Elderly Commission at the Madrid Municipality (which monitors elderly care policies and services); one representative of the National Social Workers Council (which coordinates the demands of professionals in this sector) and one representative from civil society advocating for alternative ways of organising care. It was not possible to include the discourses of the regional government as our requests for interviews were never answered.

In the case of Stockholm, the 18 interviews included six local officials who held positions of responsibility in elderly care (from six different city districts); four members of Stockholm’s Elderly Committee (policy-makers, responsible for coordinating and developing eldercare); six interest organisations (a trade union representing care workers -Kommunal, Pensioner Organisations -PRO and SPF-, an association of private care providers -Vårdföretagarna-, an association of non-profit providers -Famna- and the Swedish Association of Local Authorities and Regions -SKR). Two interviews with care entrepreneurs who head small-scale home care companies were also included, given the political importance attributed to small private providers in the Swedish choice system.

In both cities, semi-structured topic guides included the following subjects: (1) recent changes in the home care system; (2) perceptions regarding older adults’ needs and the role of care services; (3) the organisation of care services and the changing conditions and requirements for care work; and (4) public procurement procedures and the home care market.

The duration of the interviews was approximately one hour. Interviews were transcribed and analysed applying content analysis for coding and categorizing qualitative data. The content analysis employed a combination of inductive and deductive approaches to thematically categorise data, resulting in the identification of three sections for discussion: the governance of the home care service, working conditions of care workers and the existing tendering/monitoring system, in order to reflect on the needs of the public care provision system for elderly care at home. To illustrate the analysis, quotes from the interviews have been translated from Swedish and Spanish to English.

4. A comparative analysis of changes and challenges in HCS: the situation in Madrid and Stockholm

4.1. The governance of home care service

In both Madrid and Stockholm, the current regulatory framework grants elderly people a general right to receive care provision based on needs assessment, in line with the recommendations of the European Union to ensure access to LTC. In addition, in both cities, access to HCS is not means-tested but user fees are applied, depending on income. However, the differences in service management pose distinct challenges in each context, arising from different conceptualizations of the service in terms of the principles that govern it.

Madrid

In the case of Madrid, the recent recognition of care as a subjective right (2006) has led to a significant increase in coverage. Over the last decade, the service coverage for persons 65+ years has increased from 7.8% in 2011 to 9.33% in 2022, following a continuous upward trend aligned with the principle of ageing-in-place. But beyond this positive increase, informants stress problems related to the type of support provided in the households, the lack of coordination with other welfare service and issues deriving from its governance system.

The expansion of the HCS meant improvement in coverage to the elderly, but at the cost of simplifying and reducing the type of tasks performed and making its management excessively bureaucratic. It has progressively lost its comprehensive accompaniment trait, going from a close and personalised way of provision for both users and employees, to a bureaucratised service. In this sense, the improvements experienced in terms of coverage and access to the service are in line with the promotion of the "ageing-in-place" principle, but the type of tasks covered do not allow for the comprehensive support necessary to promote real autonomy in a community setting.

In those 25 years… it has been 25 years! Home help began as a smaller system, where there was greater control, greater monitoring by the Administration. (...) Those home helpers at that time gave personalised attention, from personal hygiene to... support in carrying out daily activities such as cooking, shopping... when they created accompaniment, that is, the helpers went with the person, went shopping, bought groceries where they usually did, returned home, helped them with the food.... Interview 1, Policy officer

...now the home help service is starting to be heard of a little bit more but it was ‘the great unknown’, a few years ago it was ‘the great unknown’ and it is a service now. I have been here since (19)95 but it is a service that has been there for many, many, many, many years, so the volume has been growing so much that the service is getting out of hand... Interview 6, Trade union.

The multilevel governance system that divides responsibilities between the regional and municipal government generates difficulties in coordination that delay access to the service and increase its bureaucratisation. Decentralisation of the service is considered beneficial to citizens since they perceive city councils as a closer institution with deeper knowledge of the local community and greater possibilities to provide a more agile service. New coordinating mechanisms between both administrations have recently been put in place, but they apply mostly to information management systems, and interviewees point to the need for further reforms that facilitate access and use for the end users. In this regard, in January 2023, the Madrid City Council approved a new ordinance that gives the municipal government greater flexibility in managing the HCS, allowing service to be provided to those people who, having requested the "LAPAD HCS", are waiting for an official decision. This represents a major reform as waiting lists have been a common problem since the approval of the LAPAD.

So, in other words it is very clear to me that if it were run in a different way, from the city council, the service would recover and recover the quality that it needs and that has been lost over the years. Interview 6, Trade union.

Of course [the new ordinance] is an improvement because we include beneficiaries who were not covered. Secondly, because we make it compatible with some situations of dependency, which is a before and an after. It gives the Madrid City Council a lot of room to manoeuvre. Interview 1, Policy officer.

Right now, for example, we are working on...a new ordinance that regulates home help with the city’s objective of simplifying the entire administrative procedure and being much more...much more agile in terms of processing. Interview 7, Technical officer.

The increase in the number of hours provided is highlighted as another essential resource to help people maintain autonomy in their households, since the current number of hours granted to users are not enough to meet their care needs and do not facilitate the principle of ageing- in-place. In addition, the need to redefine the service in socio-health terms is stressed, so that both social services and the health system provide a coordinated service.

Unfortunately, there was going to be a regulatory change that has fallen by the wayside, (...) and it is a shame because it increased the number of hours, or at least intended to go back to the number of hours the service provided back in 2012 (before the big crisis). We would have to increase and improve in that sense. And then an issue that we are tired of talking about, both at the level of social rights and at the level of health... is social and health care coordination. Interview 4, Trade union.

There should be more coordination. I think there should be common IT tools. Because I end up working with many information managements tools: the region’s, the city council’s, my own databases, so the truth is that it is a bit complicated. But well, if I think about it, since we started, we have improved, we haven't gotten worse; we have become better at coordination. Interview 9, Technical officer.

Stockholm

In Sweden, municipalities are legally obliged to fund and provide social care services that ensure users a “reasonable standard of living”. In the last decade, the service coverage for persons 65+ years increased from 10.1% in 2011 (National Board of Social Affairs and Health 2011) to 11.9% in 2023 (Statistics Sweden 2023). In line with the universal right to care services, the interviews in Stockholm emphasise state responsibility in care for older people as the norm. Nevertheless, informants highlight several problems and dilemmas related to the funding, organisation and delivery of public care services.

As in Madrid, all informants reflect on the changes in the public eldercare system. In this case, it was pointed out that home care users today are generally very ill and have greater care needs, many of them live with dementia and some need health care at home. While older people with very substantial care needs were cared for in nursing or care homes some decades ago, they are now living at home with extensive home care. Since many older people live alone -it is very unusual for older persons to live with their adult children- some require home care both day and night, seven days a week. Informants often argue that the “ageing-in-place” principle has been exaggerated, while places in residential care have been reduced. Considering this development, HCS are described as being in between social care and health care (Peterson and Brodin 2021), and coordination problems are often reported. In this vein, the focus falls on the challenge of reorganising HCS in order to manage both health and social care provision in the home 24/7.

When you get to a point where you need help, then you need quite a lot of help. You need a lot of home care, you need a lot of home nursing (...) So it’s more about care and nursing care; how can this be organised so that we can manage: 24 hours, 7 days a week, 365 days a year? Interview 9, Association of local and regional authorities.

At the same time, many informants express concerns about the “financial sustainability” of the system. One policy-maker emphasises, for example: “the system is leaking money today, and we won't be able to afford that in the future” (Interview 8). Some of the informants refer to the question of financial sustainability to justify further targeting of those elderly with the greatest needs and exclusion of those with lesser needs. In fact, continued targeting is taken for granted in some interviews; older people are assumed to contract cleaning and other domestic services privately, regardless of their needs or financial resources.

Marketisation is also a central theme when informants describe HCS and how the system has changed over the decades. In particular, marketisation involves the idea of customer choice, meaning that service users are allowed to choose their organisation providers of care services from a previously approved list. There are divergent perspectives on this development, but many of the informants describe customer choice as a win–win situation, leading to a more efficient system with diversified providers and services, on the one hand, and to freedom of choice and influence for individual users, on the other. The customer choice system has been expected to improve quality as users can change providers if they do not receive good care.

The freedom of choice system, as I see it, has led to increased freedom of choice for the individual, a basis for quality work, and it has also led to the reduction or disappearance of home care services that were not perceived as being in demand. Including both services provided by the municipality and those provided by private companies. Interview 9, Association of local and regional authorities.

Marketisation of care though customer choice is assumed to generate services tailored to fit individual “preferences” of a diverse older population. Home care companies can develop different “profiles” (e.g. related to lifestyle, habits, and language preferences) to attract customers. For example, one policy officer argues regarding customer choice: “above all, it’s positive that so many different types of home care have developed” (Interview 3).

However, the informants also recognize that older people seldom change care providers. Since social relations constitute an essential element of care, older users often prefer continuity. In addition, customer choice only allows choosing between the public provider and numerous private care companies. Hence, choice is not about choosing specific services or care workers. When the informants talk about choice and preferences, they tend to overlook older service users’ positions of extreme dependency and vulnerability, which contrasts with the way they previously described users of HCS.

4.2. Working conditions and the care profession

The professionalisation of HCS, including formal education requirements, has been encouraged in recent years in both countries, through explicit strategies to improve the status of care work and make it more attractive. In that sense, specific training programmes are now required to enter the sector. These training requisites contribute to de-essentialising the care sector with the idea that care activities are not “natural female competencies” but rather a profession that needs specific training. However, women continue to hold most care-related jobs and poor employment and working conditions remain a serious problem in both contexts.

Madrid

In the case of Madrid, the precarious working conditions of nursing assistants are directly related to the privatisation model observed in this city, and generate a mismatch between the labour expectations of an increasingly professionalised sector and the precarious conditions in which they provide the service.

The outsourcing process has led to a significant decrease in the existing coordinating mechanisms between companies, employees and users. The three companies involved in HCS manage very large lots with substantial spatial dispersion of districts and without ensuring the presence of coordination points. This scarcity of coordination posts contributes to the atomisation of the service, producing a mismatch between the principle of ageing in place and the community perspective that HCS seeks to promote.

[Before LAPAD] We all worked here, we all lived in Fuenlabrada [a city in the southern part of Madrid region], we had our office here. We could even talk to the coordinator's superior, to the person in charge of coordination, if we wanted to talk to her. The coordinators were at their desks as we entered, and the head of coordination had a separate office, so we could talk to her. (...) Once we moved to dependency [LAPAD] we worked all the southern area and we had a single office, a huge office with 40 million coordinators... Interview 3, Trade union committee.

The mismatch between the growing demand for professionalisation and the working conditions is a major disincentive to work in the sector. The increasing educational requirements has not led to greater specialisation of the work, but rather just the opposite. In Madrid, informants state that the rapid extension of the HCS since the approval of the LAPAD has led to a trivialisation of the service, seeing the HCS as an opportunity to have a "cheap" domestic worker. Training should thus be focused on the improvement of users and employees’ everyday conditions, considering them both to be at the centre of the service.

In the end they have turned it into a cheap domestic help from the city council. That's what the service has become, it has, it has been lost (...) People, you know, have a lot of nerve, and do not use the service for what it is (...) I cannot arrive at a household and have them there waiting for me with a mop bucket, because my main function is to attend to the person. Interview 6, Trade union.

Thus, HCS workers now devote a significant part of their time to household chores, focusing less on care-specific activities. In addition, low wages in many cases prevent employees from accessing a decent quality of life; most contracts are part-time, leading workers to combine this employment with other jobs in the formal or informal economy. Moreover, commuting between households is not counted as working time, resulting in working overtime under stressful conditions.

So, we deserve a decent salary for the work we do. (...) I am a 30-hour worker and after 15 years, I earn 900€. After 15 years...And I add to that salary for seniority, because the basic salary for 30 hours is: 767 €. Interview 3, Trade union committee.

You will see the conditions in which they work. At ten o'clock at night they are contacting them about the next day's service...They are told the timetable totals, but not including the commutes, so it is as if they work ten to twelve hours... Interview 1, Policy officer.

These precarious working conditions are incongruent with a type of work that often requires significant personal involvement and makes it difficult to separate personal and work time. Users, faced with the shortage of time for care, often require a relationship that exceeds the established hours and expected commitment. Similarly, workers can sometimes overstep the boundaries of their duties as a consequence of the long and close relationship involved in the service.

...there are many times that, if we stay in a service for a long time, there are workers that, in the end, act as if it were their home and that can't be.... There is a very fine line in this job, it is very fine, but you cannot cross it. (...) That fine line cannot be crossed, because in the end they believe that you are their property, just as we believe that, when we cross that barrier, they are our property... Interview 3, Trade union committee.

Stockholm

The characteristics and conditions of care work have also changed over time in Sweden, in this case as a result of social reforms, cutbacks and marketisation. When home care first emerged, care work in this sector was not considered a profession but was instead associated with the unpaid activities of housewives; hence, no specific education or training was required (Szebehely, 1995). Professionalisation, including formal education and training requirements, developed as a strategy to improve the status of care work and make the work more attractive. Additionally, the core of the work has shifted from mainly performing household tasks towards caring for increasingly sick and frail older people.

HCS for older people is described as a difficult and demanding job. Central in this discourse are the before-mentioned changes in the Swedish care system that have taken place in recent decades. Due to the decline of residential care, the nature of the job has changed. The informants emphasise that today home care workers assist older people with significant and complex care needs requiring very intensive help. In addition, workers assist older people with dementia and other illnesses and, sometimes users with psychosocial problems.

We have people with psychiatric diagnoses, people who are bedridden around the clock, people who have severe substance abuse problems, we have very heavy- care-heavy - people living at home. Home care staff must have the competence to deal with them. It’s not peanuts, it’s basically quite a demanding profession. Interview 1, Policy officer.

In this vein, informants argue in favour of continued professionalisation, notably by increasing the level of formal education and training, and hence the proportion of qualified assistant nurses. Care providers are required to develop strategies to increase the level of qualifications among their staff, and progress in the level of staff qualifications within care companies is monitored by the local authorities in Stockholm.

While most of the informants consider work in the home care sector to be skilled work, requiring formal qualifications, education and training, they also emphasise that the conditions that characterise the sector constitute an obstacle for professionalisation. Home care workers have fought for -and gained- rights over the years, but poor employment and working conditions are still a problem in this sector, as happens in Madrid. A representative of the care workers’ trade union highlights the insecure employment conditions, with many employees being paid by the hour. The fact that basic staffing levels are too low in general is also highlighted, in connection to stressful workdays. These problems are linked to marketisation and profit-making.

The problem is that the price is fixed, and the amount of work is set. How do you make a profit? Well, the way to make profit is, from our point of view, to lower costs. And the easiest way of lowering costs in operations that are so much about staff (...) is to lower the cost of personnel. Interview 16, Trade union.

In contrast to Madrid, travel time is generally counted as working time. Nevertheless, since time slots in users’ homes are tight and distances in between are sometimes considerable, travelling may add to stressful workdays. A recurrent theme refers to work in home care as “chasing minutes”. The outsourcing of care services to private providers has generated greater distance between needs assessments (public) and care provision (increasingly private). Increased detail in needs assessment decisions is required and, therefore, each work task is linked to a standardised time frame (Meagher et al., 2016). For care workers, the short minute-based interventions, in combination with the digital time recording system, creates stress and decreases flexibility. In this vein, minute-by-minute management is connected to poor working conditions. The representative of a pensioner organisation argues that the improvement of working conditions is not only important for care workers, but also for older service users.

We think that this system is bad, when it comes to time recording, the minute-steered system, you know. We say it like this: what is good for the staff – they should have a good working environment and working conditions – is also good for the elderly. We think there is an important connection there. Interview 13, Pensioner organisation.

While care work is acknowledged as a job that requires education and training, the informants emphasise that recruitment of qualified care workers is difficult. Home care is low paid and undervalued, with little real recognition of the skills involved, and hence it is not considered attractive.

Home care service has a bad reputation, low status, is poorly paid, and is a “passing through” profession (…) No, people don’t want to work in home care. Interview 5, Local authority official.

It is also highlighted that home care workers who study and achieve the qualification of assistant nurse tend to look for work elsewhere, mainly in residential care or hospitals. Informants believe that assistant nurses want to perform different and more specialised work tasks, but they also relate it to the higher status of care work in other settings. To promote professionalisation, some informants argue that future home care should distinguish more clearly between “care” (personal care and nursing tasks) and “household work”, as the latter could be performed by “unskilled” domestic workers outside of the public system.

4.3. Tendering and monitoring systems

Although the outsourcing-privatisation process exists in both cities, in the case of Madrid the service is completely outsourced to private companies, while the scenario in Stockholm combines public services and a high number of larger and smaller private companies.

Madrid

In the case of Madrid, discourses coincide accepting the outsourcing of the service as a necessity derived from the rapid growth of the service and point out that municipal public management would not be possible (contrasting with the Swedish scenario where public participation is integrated into the service).

…what I remember, I have been working in the city council for 25 years, and there has never been a municipal service. It is very complicated; it would be practically impossible to make it municipal because you realise that there is a lot of mobility [among the assistant nurses], the complexity of this service... Interview 10, Technical officer.

Despite accepting the externalisation process, informants express doubts about how this outsourcing has come about and how to improve the current model of service management, understanding that the model fails to provide a personalised care service. The bidding process consists of dividing the city's 21 districts into three large lots, each assigned to one private company. The management of such a large number of services results in only large companies being able to participate in the tendering process, some of them joining the care sector without any specialisation and only as part of a strategy to expand their presence in new market niches.

Now the feeling is that the company in charge manages a shopping centre and a home help service, and a security service. So, it doesn't matter a bit; it's a business, it's a business and it doesn't matter. Interview 8, Technical officer.

This bidding process has been carried out through terms and conditions that have given priority to economic offers over technical aspects (the type of care provision offered), which explains the entry in the sector of large companies with no previous experience. This prioritisation of budgetary factors over technical criteria has led to criticism and proposals for revision.

You have three parts, the price, the project and the improvements and I think it is more about rethinking that certain basic requirements could be raised. Because what I am seeing now is the highest bidder, as if they were going to buy milk...Interview 11, Social Workers Council

Beyond the process of bidding, the monitoring and coordination mechanisms between the municipality and the companies are strictly focused on the periodic management of the number of people requiring care. Other aspects related to the type of care provided or the working conditions offered to the assistant nurses are not part of the usual coordinating protocol.

Small-scale businesses and cooperatives do not participate in HCS in Madrid. Informants believe that their entry might be promoted through the development of different bidding terms and conditions and through the inclusion of social clauses to improve the working conditions in the sector and contribute to anchoring it in the territory. This participation, nevertheless, would also pose some challenges, as the case of Stockholm shows.

Stockholm

Formerly a publicly provided service, Swedish HCS has been increasingly outsourced to private (mainly for-profit) providers. The Local Government Act (1992) introduced the option of splitting the service between purchaser (the municipality) and provider (mainly companies), which made it possible for municipalities to outsource service provision. This development was strengthened by the Public Procurement Act which regulates the process of outsourcing through competitive tendering, in line with EU legislation. As in the case of Madrid, participating in such procedures usually requires a large number of resources to invest in repeated bidding processes and use economies of scale, consequently favouring large companies. When the choice system was introduced in 2008, politicians argued that this system would encourage small scale HCS businesses because all care providers that comply with the formal requisites are included in the system where they compete for clients (Brodin and Peterson, 2020; 2023).

In the case of Stockholm, many of the informants describe this kind of marketisation of care as women-friendly. Policy-makers, local authority officials and interest organisations express positive and optimistic ideas about women's care entrepreneurship. Small-scale care companies in Stockholm are predominantly run by women, hence informants argue that starting and running small-scale care companies in the home care market is an “opportunity” for women who are already working in the home care sector.

In these soft professions, I was going to say, it is often women who work. And it’s good if women can come forward […]. They may have worked in the industry and then started a company in the same industry, so that’s great! Interview 4, Local official.

Women care entrepreneurs are generally described as entering the market with relevant experience and knowledge from having worked in the care sector. Several informants therefore also assume that female care entrepreneurs have certain ideas about care that they can translate into better care for older people. In sum, since the choice system has opened up HCS to women-led, small-scale care companies, it is seen as good for women and potentially good for older service users. In addition, the small-scale care providers are sometimes described as having closer ties to specific localities than the bigger companies.

Despite these optimistic views of the choice system and women's care entrepreneurship, the informants point to numerous problems. While the local authority officials express mistrust towards small companies, the care entrepreneurs emphasise that large companies are favoured in many ways. Notably, policy-makers and local authority officials sometimes describe small-scale care entrepreneurs as amateurs or cheats. In this vein, the city has recently developed stricter market entry requirements to improve quality and reduce the number of companies to facilitate oversight. Further, the interviews reflect the tension and conflicts between local authorities and private care providers over matters related to reimbursement. Reimbursement to providers occurs based on the time recorded by staff in the home of the older person, as long as it is within the time granted through needs assessment. Home care providers must report the time spent with users, the type of interventions and social documentation in Stockholm’s digital reporting system. When care staff exceed the time granted, it must be explained. Given the short time-frames home care workers have with users, care workers sometimes have to stay longer to assure adequate care.

We had one customer, she was really gravely ill. The staff worked a lot of extra time. We tried, tried to get them to pay overtime and they said no. But the person was dying, so to go and leave her at the end of the time, saying "I'm leaving now", it's not possible! Just that quality, that humanity, we have to give it (…) So we take longer (time), and the municipality doesn't care about that time. Interview 17, Small-scale care company manager.

Overall, the economic sustainability of small-scale care companies was questioned in the interviews, most notably in the interviews with the care entrepreneurs themselves. Surviving as a small home care company is described as a struggle, due to harsh competition from bigger companies and low economic compensation.

5. Conclusions

The analysis of the situation in the city of Madrid and Stockholm makes it possible to reflect on the necessary adaptations of their welfare models to the needs of a growing elderly population that requires new care services. In this sense, the general socio-demographic context of the two cities presents similar trends, although their public social services systems show clear differences. The Swedish social commitment to care services has historically experienced a more solid development, with the focus on universality, equality, affordability and socio-economic transversality. The Spanish case, on the other hand, was developed more recently and is only now moving away from the idea of institutionalised and health-driven service. The turning point in Spain was the approval of the Dependency Act (LAPAD) in 2007, recognising the subjective right to provision of care and defining a governance system that requires the coordination of regional and municipal administrations. In Sweden, the Social Services Act (1982) establishes the legal framework, but the local city council also formulates and adopts the eldercare policies, and the districts are responsible for needs assessment and continuous monitoring of providers.

In both cities the socio-demographic context requires changes, but each case has employed different formulas. In Stockholm, the difficulties in meeting the increasing demands have been solved by concentrating HCS resources in the frailest elderly, those with most severe care needs. The given service is, therefore, focused on personal care in highly complex cases. In Spain, the growth of the service has been addressed by decreasing the hours of attention so that more people are covered by the HCS but with fewer hours. Moreover, the service has shifted to tasks more related to domestic work.

In both cases, the discourses express a degradation of working conditions. In Stockholm these are more related to the tailorisation of the service, as every task is controlled by technology, while in Madrid they are in connection to the loss of close relationships between workers and with users, as bureaucratic processes get imposed. In the latter, the degradation of working conditions is related to the complete outsourcing of the service to large private companies with little experience in the sector, since public bidding requirements have prioritised economic proposals over technical ones. In Stockholm, individual choice has been introduced as a key principle, promoting the increased influence of the elderly but resulting in increased monitoring and unnecessarily detailed oversight. The idea of opening the market up for small care companies -thereby promoting women's entrepreneurship and more locally rooted care businesses- contrasts with the difficulties of such companies to survive in Stockholm’s home care market while ensuring good care for clients. In Madrid, in this sense, the idea of collective support is linked to improving the working conditions of all the employees in the sector, considering that small companies cannot improve working rights if there is not an improvement in the general care structure.

The necessary redefinition of the current model of public care provision must thus overcome the aforementioned shortcomings. In relation to working conditions, employee stress could be lessened by simple actions such as loosening up time control over workers. In the case of Stockholm, technology should not be used to reduce autonomy and personal decisions in care tasks, and for the city of Madrid, time investment in transportation should be considered as working time in order to reduce the total burden on the care worker.

Another element that should be taken into consideration is related to the idea of ‘ageing- in-place’. There should be a proper definition of its benefits and the ways to carry it out, since in Stockholm it seems to have been taken too far (in the way that the most fragile cannot be properly attended to at home) and in Madrid it seems to be developed independently from the whole idea of community and territory. A concrete definition of this concept might allow for better use of resources.

Finally, the bureaucracy involved should also be improved and bidding processes modified. In the case of Madrid, excessive bureaucracy is mainly in place because of the inefficient coordination system between the different levels of government, while in Sweden it is the result of the strict public monitoring system required to control the numerous providers in the care market. Changes should be made to allow bidding processes that do not exclusively favour big companies, since this means keeping women-led and cooperative-based providers out of the home care sector.

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JEL Classification: I38; J14; Z00

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redalyc-journal-id: 289