Substituting professional with informal care? A response to “how to handle gerontocracy”

Abstract

Purpose

The comment addresses the idea of substituting professional elder care with informal care provided by early retirees to save economic costs.

Design/methodology/approach

The comment arose from reading “How to handle gerontocracy”, scientific research and critical, analytical thinking.

Findings

While having early pensioners deliver elderly care has positive implications, substituting professional with informal care must be challenged. First, the “unused reservoir” of early pensioners might be overestimated, as they often already have care responsibilities. Second, the substitution of professional services is already happening due to staff shortages. Third, untrained caregivers might struggle to provide the needed care quality, resulting in worse health outcomes (and higher follow-up costs). Finally, there are concerns of social sustainability: because of role expectations, mainly women may take on care tasks, reinforcing social inequality. Also, the third sector might lose hours of volunteer work.

Originality/value

The comment appeals to a critically rethinking of the idea of substituting professional services with informal care provision and argues for differentiated and well-tailored policy measures, taking into account the complex nature of (informal) caregiving.

Citation

Gösenbauer, B. (2023), "Substituting professional with informal care? A response to “how to handle gerontocracy”", Journal of Integrated Care, Vol. 31 No. 5, pp. 129-132. https://doi.org/10.1108/JICA-08-2023-0063

Introduction

The following statement refers to a recent article by Canoy et al., addressing the current demographic development of “gerontocracy” as a socioeconomic as well as a democratic issue (Canoy et al., 2023) and picks up on the idea of using informal elder care by early retirees as a substitute for professional services.

While I agree with the authors that (European) countries do face an incremental crisis of generational imbalance in socioeconomic terms as well as concerning democratic representation that demands fast action, I would like to question one of the key suggestions they propose in their paper: the idea that informal care, taken on by retirees and performed for their (older) peers, can serve as a substitute for costly professional services. As is stated by the authors, there are many advantages of their “elderly for elderly” idea of caregiving: for the tax payers who save money on professional services, the pensioners who counteract loneliness and make a meaningful societal contribution (Canoy et al., 2023), as well as the patients who probably prefer being cared for informally at home (Antonucci et al., 2011). However, the solution might not be so easy as to simply substitute (expensive) formal with (supposedly cheap) informal care. First of all, it needs to be clarified if this pool of recently retired younger elders is actually “unused” as informal caregivers are a very heterogeneous group, including people in this age group that play a vital role in maintaining care supply (Bainbridge et al., 2021; Greenwood et al., 2019). Second, the substitution of professional work with informal caregiving has already been happening due to a lack of professional staff that needs to be compensated or substituted (European Union, 2021; Van Houtven and Norton, 2004). And third, it is to be questioned if a substitution would really be “cheaper” within an aggregated and long-term societal perspective or if it would entail expenses elsewhere (e.g. as a result of unmet care needs that lead to higher costs due to treatments of probably avoidable health conditions).

The unused reservoir?

While the wording of an “unused reservoir of potential informal caregivers” that is to be “exploited” (Canoy et al., 2023, p. 162) can itself be questioned against a background of ethical considerations of autonomy, one might doubt that this reservoir is actually as “unused” as depicted. Keeping in mind that many informal carers that provide care for the elderly are already older and often even retired themselves – especially when it comes to spousal care (Bainbridge et al., 2021; Swinkels et al., 2019) – weakens the assumption of a pool of freshly retired just-over-60s, waiting to chip in. Furthermore, against the background of a life filled with gainful employment (or some form of productive work) as well as reproductive (care) work at some point, it might be more difficult than expected to draw those without direct current care responsibilities into voluntary caregiving right away.

Informal care – a new substitute?

Contrary to what the paper indicates, the substitution of professional services with informal care provision is already happening. Since our goal as a society is to maintain a certain level of health even in old age (United Nations, 2015), quality care is mandatory. As, within an ageing society, the share of old and multimorbid persons is rising, the demand for (professional) care is growing, facing a shortage of trained staff and making professional care a scarce good (Estrada Fernández et al., 2019; European Union, 2021). Therefore, informal care is and has been provided to complement or even substitute formal services (European Union, 2021; Van Houtven and Norton, 2004). Informal care is increasingly necessary to avoid unmet care needs, and it already functions as a substitute for professional services. The share of older people is rising due to demographic changes like longer life expectancy and decreasing birth rates in European countries. At the same time, the supply of trained staff cannot keep up (the pool of possible future nurses is getting proportionately smaller). Consequently, the gap between demand and supply of (professional) care is rising, and a substitution of professional services is inevitable. But this substitution is not necessarily wanted – it is the only way. Against this background, arguing to cut back on professional services and replace them with voluntary work by mostly untrained retirees to save economic costs is probably not a realistic way to go, especially when trying to provide a certain quality standard on average.

Informal care – a cheap substitute?

From an economic or state perspective, informal care provision is certainly less expensive than formal supply. Depending on what is factored in as cost, informal care might even be considered free of charge. From a societal perspective, this approach falls short. Returning to my previous point, informal carers might not be able to fulfil all necessary tasks to maintain a certain quality of care simply due to a lack of training (nursing is a diverse and skill-requiring job). Therefore, health outcomes of patients may decrease, leading to more severe health problems that entail more expensive treatments. It is questionable whether informal care really is more cost-effective in the long run and against a comprehensive perspective.

To avoid this, at least some basic training of informal carers and regular supervision by professionals are needed. This might still be cheaper than a professional-only situation, but often it is a form of shared care, combining some professional help with informal care provision (European Union, 2021). But even with training and supervision, providing informal care is burdensome on a physical, psychological and social level and might be accompanied by adverse economic and health effects for the caregiver (Antonucci et al., 2011; Bom et al., 2018; Dowling, 2021; Estrada Fernández et al., 2019; Folbre, 2018; Gérain and Zech, 2019). Consequently, if we as a society put too much pressure on informal caregivers, we might end up with even higher costs, as we would soon have to care for them too.

In conclusion, relying mostly on and fostering informal care primarily seems to be cheaper than professional services, but there might be follow-up costs that diminish or even reverse its cost effectiveness, namely, unmet care needs of patients that result in bigger health problems requiring more expensive treatments as well as adverse effects on caregivers making them more likely to develop their own care needs sooner.

Informal care – a socially sustainable solution?

While the “elderly for elderly” idea is promoting reciprocity and solidarity, it might not be a socially sustainable solution (if used as a substitute for formal care).

First, if leisure time is allocated increasingly towards informal caregiving, the third sector will lose hours of volunteer work, constitutive for charitable and nonprofit organisations and initiatives as well as many community activities. One might think about sport events, educational initiatives like health talks or children's programmes, cultural offers from musical associations or theatre groups, etc., which pensioners may not only attend but also organize.

Furthermore, there is a gender dimension to it: due to gendered role expectations within society (especially among older generations), it seems likely that primarily women will heed the call. They are viewed as responsible for care work (Greenwood and Smith, 2016; Zygouri et al., 2021). After a lifetime of phases of unpaid (and often “invisible”) reproductive work, women as a societal group are on average already more affected by economic vulnerability (Dowling, 2021; Folbre, 2018) and adverse health effects (Bom et al., 2018), stemming from informal care arrangements, than their male counterparts. If these problems are not considered within the policy incentives to increase informal care, there is a risk of women being left with the lion share of informal caregiving and all its negative effects again. Therefore, if informal care should be defined as a goal, it is also necessary to target (potential) male carers and to provide sufficient and differentiated support (like respite offers, trainings, supervision, etc.), matching – and if necessary, altering – country-specific structures and policies.