Negotiating care in the context of Finnish and Italian elder care policies

Abstract

Negotiation is an integral part of all elder care, which by definition involves a relation between at least two people. In this article, we analyse negotiations concerning elder care in the context of Finnish and Italian elder care policies. At the macro level negotiations on elder care are shaped by elder care policies and at the micro level by individual skills and resources. Our focus is on the negotiations on eligibility that take place when elders attempt to access care. The data consist of qualitative interviews with Finnish and Italian elders in need of care. The analysis of individual experiences of care negotiations reflects the practical consequences of elder care policies to older people. The results indicate that the most negotiated eligibility criteria when seeking access to elder care are need, money and social relations. These criteria are negotiated when seeking eligibility to different sources of care: informal care, grey market, market-based, non-profit and public services. In Italy, negotiation is particularly crucial when accessing grey market care. Cash as the main Italian elder care policy tool tends to enhance the role of and need for negotiation. In Finland, a greater part of elder care is provided by the public sector and therefore the process of negotiation is more standardized than in Italy.

Introduction

The provision of care is inherently a social process that involves at least two but usually more people. In this situation when things have to get done, it is necessary for people to negotiate with one another (Strauss 1978, p. 2). In elder care, negotiation is particularly important at the point when the person who is in need of care seeks to gain eligibility to care which may be provided by family members, friends, public or market-based services, non-profit organizations or by grey market actors. The role of these different care providers depends not only on individual negotiations, but also on broader policies of elder care.

This article is concerned to explore negotiations surrounding elder care in situations where Finnish and Italian elders are aiming to gain eligibility to different sources of care. The focus is on the older person in need of care, which so far has received less research attention than the carers’ perspective (see Capezuti et al. 2007). In addition, it has been shown that the use of social and health care services does not necessarily depend solely on the actual need for services, but people in higher social class positions and in better health tend to use these services more than others (Coulton and Frost 1982).

Our specific aims are, firstly, to identify which issues are negotiated when older people negotiate their eligibility to different sources of care. Secondly, we want to know how these issues are negotiated. Based on a set of interviews with older people in Finland and Italy, we consider different types of care in which eligibility varies widely. There are also national differences in elder care policies which form the policy context for the negotiations. We argue that how the negotiations unfold depends on individuals and their skills and resources in negotiation, the availability of different sources of care as well as on care policies. Cross-cultural comparisons are useful in studying negotiations on care as older people living in different countries may have similar needs for care, but national care policies may differ widely. Therefore, by looking at the micro level process of negotiation we can shed light on policy level issues, since this is where policies are implemented and lived by individuals (see Silverman 2000, p. 86).

The article proceeds as follows. Firstly, we define what we mean by care and introduce the theory of negotiation. Secondly, we present our data and research methods. Thirdly, we move on to provide a brief introduction to Finnish and Italian care policies. Fourthly, we analyse negotiations on eligibility to different sources of care in two policy settings. Finally, we discuss the results in relation to elder care policies in Finland and Italy.

Negotiated care

Care refers here to the multiplicity of help and assistance that older people need to manage with activities of everyday living such as eating, cooking, cleaning, dressing and washing up (cf. Sipilä 2003, p. 23). Care may be received from various sources such as friends and family members and public, market-based, and grey market health care and social services. Eligibility to different sources of care, i.e. access to or the right to receive care varies greatly. Regardless of the source of care in question, there are certain criteria that the older person has to meet to be eligible to receive care (cf. Evans and Harris 2004, p. 883). In the case of public services, eligibility is often determined by needs or means-testing. In market-based services, eligibility goes hand in hand with affordability. Money is also essential to eligibility in grey market services, whereas in informal care, eligibility depends mainly on existing social relations.

Eligibility is usually preceded by an expression of the need for care. This is often done verbally by asking for help or by applying for services. This verbalizing of need for care, which aims to guarantee eligibility or access to care, is what we call negotiation. Verbal negotiations are by definition explicit; the parties involved are aware of the process of negotiation (Strauss 1978, p. 244). Negotiations may be also implicit, without words and without the people involved being aware of the process (ibid. 224). Implicit negotiations are habitual ways of acting that have developed over time (Finch 1989, pp. 180–181). They are often assumed about how the other party will act and behave (Strauss 1978, p. 224). Negotiations are needed to say who is entitled to what kind of care and from what sources (cf. Zartman 1976, p. 2). Negotiations aim, but do not always succeed, to create a shared understanding of what that need actually is and who would be able to provide it (Finch 1989, p. 194). Negotiations on care needs and care provision are conducted with public, market-based, non-profit and grey market service providers when older people turn to those services in search for help.

In this study, we have drawn on Anselm Strauss’s (1978) theory of negotiation emphasizing the essential properties of negotiations. These properties include the number of negotiators, the repeatability of negotiations, balance of power, the nature of stakes, the visibility of transactions, the number and complexity of issues negotiated, whether the parties have the same goals, the clarity of legitimacy of issues negotiated and the options of avoiding or discontinuing negotiations (ibid. 1978, pp. 99–100).

Elder care negotiations typically involve more than two people, but due to the nature of our data,1 and to highlight the view of elderly the focus in this article is on negotiations taking place between an older person in need of care and one other person, usually a family member or a care worker (public, market-based, non-profit or grey market), or a professional who decides on referrals or on service eligibility. Elders represent themselves in the negotiations, but at times they may resort to representatives such as family members, friends and professionals (Strauss 1978, p. 202). Negotiations on elder care tend to be repeated (cf. ibid. 99) as the need for care may vary even during the course of the day, and at times care provision may end and have to be replaced. The balance of power (ibid. 100, pp. 209–210) varies considerably depending on who is negotiating with the older person in need of care. If that other person is a family member, the balance of power is likely to be very different compared to the situation where the negotiations are conducted with a doctor who may refer the elderly person to public home care services. The balance of power also depends on elder care policies, which may for example specify certain rights for older people in relation to care. Furthermore, the balance of power is also dependent on various resources, such as money and social networks to which the older person has access.

As regards the stakes involved in negotiations about eligibility to elder care, these are often very high: not being eligible to receive care (say regular meals-on-wheels) may severely compromise everyday life. Older people often do not have the option (cf. Strauss 1978, p. 238) of avoiding negotiations since their care needs are essential to their daily life. Care needs can and often do vary widely in complexity (ibid. 100). The need for assistance in shopping, for instance, is not a very complex need, but when needs accumulate and assistance is needed in several daily activities, the negotiation process tends to become increasingly complex. This also relates to the clarity of issues negotiated, as needs for care are not always easy to measure objectively. From this it follows that other people may question the legitimacy (ibid. 112) of needs and demands for care.

The parties involved in the negotiation process may have similar goals (Strauss 1978, p. 237): to make sure that the older people get the help, assistance and the care they need. Often there are other goals involved as well, such as saving public money, making a profit, ensuring a good livelihood as a migrant care worker, relieving the workload of an informal carer, and so forth. Older people may also have collateral goals from receiving care, such as saving money or influencing the life of friends and family in one way or another.

Besides the different negotiating actors, also the context influences the negotiations. In our data, negotiations take place in the Finnish and Italian welfare states, and more specifically in the context of elder care policies. These policies set the general framework conditions for the negotiations, defining for example who is responsible for the provision of care for older people in the society concerned (see Strauss 1978, p. 124). In this case, care is formally a public responsibility in Finland and a family responsibility in Italy. Negotiations constantly take place in continuous interactions between older people and carers, and the outcomes are shaped by elder care policies in different ways (cf. Lipsky 1980).

Interview data and research method

Our data consist of 15 qualitative interviews (see Rapley 2004, p. 15) conducted in 2005 with older adults in need of care in Finland and Italy. Using these interview data and a qualitative approach, our aim is to understand the views and experiences of older people with similar care needs but in different policy settings (see Silverman 2000, p. 90; Snape and Spencer 2003, p. 3). The Finnish data from the Tampere region comprise ten interviews with five women and five men aged 66 or more. From the Siena region in Italy, we had interviews with four women and one man aged 67 or more. The interviewees were recruited with the assistance of home care services in both countries. In Finland, some interviewees were also found through a carers’ association. The data are selected from a larger data set which consists of interviews with care givers and receivers.2 The interviewees were purposely sampled so as to cover as wide a variety of care sources as possible (see Snape and Spencer 2003, p. 5).

At the time of the interview, the Finnish women were aged 70–87 and the Finnish men 66–81. The women in Italy were 67–85 years and the male interviewee was 79. The need for care varied, but all the interviewees needed regular assistance, most of them requiring daily help and care (see Appendix). The care they received came from various sources: family members, friends, non-profit organizations and from public, market-based and grey market services. During the interviews, a care trajectory was constructed: from the time the need for care arose to the time of the interview.

The data were analysed using qualitative content analysis, clustering similar utterances into conceptual categories (Weber 1990; Cavanagh 1997). We began by grouping the different sources of care mentioned by the interviewees: public, non-profit, market-based and grey market services as well as informal care. Next, we identified the main eligibility criteria for each source of care. This was the first phase of the analysis. In the second phase, we focused on how the eligibility criteria were negotiated when seeking care from different sources and in different policy settings. The analysis proceeded in orbicular way where theoretical concepts and empirical findings are in constant dialogue. The qualitative and interpretative approach was adopted so that we could study and understand older people’s individual negotiation processes as well as the policy contexts in which the negotiations take place (see Silverman 2000, pp. 86, 152). Before moving on to discuss the results, it is useful to look briefly at elder care policies in Finland and Italy.

Finnish and Italian elder care policies

The reason we chose to include both a Finnish and an Italian region in our study was so that we could embed the negotiations in two different elder care policy contexts. Italy makes a powerful contrast to Finland in that it emphasizes income transfers and represents a familistic welfare state where care for the elderly rests firmly on families, while public services are the last resort (Bettio and Plantenga 2004, p. 99). In Finland, family members are not legally responsible for their elderly family members. Public services have a bigger role in elder care than income transfers (Anttonen 2009). These country differences in elder care policies give rise to many differences in the provision and practices of care.

In Finland, responsibility for the provision of services to residents rests with local authorities, although public services are now increasingly being outsourced to market-based companies (Anttonen and Häikiö 2011). Italy also has a national law that aims to establish a minimum level of social care services provided by local authorities, which are often produced by non-profit organizations and companies as well. However, there are marked regional disparities (Gori et al. 2003, p. 62). Public social care services are generally means and needs tested in Italy, but only needs tested in Finland (Gori and Da Roit 2007; Lehto 2002).

The biggest source of elder care in both Finland and Italy is informal care (Wiener 2003, p. 3). However, Huber et al. (2009, p. 72) estimate that 22 percent of Finnish people aged 66 or more receive formal long-term care services, whereas in Italy the percentage is below five.3 In 2010, 5.5 percent of people above 67 in Finland were in long term institutional care4 (SOTKAnet 2011), compared to less than 2 percent in Italy in 2007 (Huber et al. 2009, p. 89).5

In Italy, informal care has been a long-standing policy emphasis, but since the mid-1990s Italian families have increasingly hired immigrants to substitute the diminishing supply of informal care (Gori and Da Roit 2007). At the same time, this recruitment of immigrants for care work at homes has hindered the growth of public home care (Bettio et al. 2006, pp. 274, 278) and market-based supply (Da Roit et al. 2007, p. 664).

Both countries support informal care. Finland provides a carer’s allowance6 to carers, and in 2008 less than 3 percent of the population aged 65 or more received informal care supported by the allowance (Heinola et al. 2010, p. 35). In Italy, care allowance7 is paid to the person in need of care based on a needs assessment. In 2003, around seven percent of the population aged elsewhere 65 or more received the benefit (Gori and Da Roit 2007, p. 61). No means testing is applied to the Finnish or Italian allowances (Zechner 2010b; Da Roit and Le Bihan 2010).

Services for the elderly are also provided by non-profit organizations. This is the main mode of welfare service production in Italy (Egger de Campo 2007, p. 59). In Finland, non-profit organizations concentrate on certain service niches, such as sheltered or intensive care housing. In both countries, non-profit organizations produce services as part of the public service sector (outsourcing), as market-based enterprises or as volunteer-based or charity organizations (Ascoli et al. 2002; Myllymäki 2003). In this study, we refer to non-profit organizations only when they work on a voluntary or non-profit basis.

Market-based service production is fairly limited in both countries, but on the increase. It is estimated that in Italy, 4.2 percent of households with a member aged 65 or more use market-based home help services (Gori et al. 2003, p. 63). In Finland, almost 80 percent of all home care services are provided by local authorities, the rest is purchased from market-based companies (Care and services for older people 2005 (2007, p. 62). The Finnish government encourages people to purchase services from companies with a tax rebate, where a part of the labour costs incurred from the purchase of these services is eligible for a tax deduction.

Elder care policies in Finland and Italy are built around the same basic elements, but there are differences in emphasis. In both cases, informal care is predominant. In Finland, care provision still relies heavily on public services, although it has been suggested that their role is now dwindling (Julkunen 2006, Anttonen and Häikiö 2011). In Italy, public services have always had a marginal role. Grey market arrangements have continued to gain in importance in Italy, whereas in Finland they have never been very prominent. The non-profit sector is an important service provider in both countries, and market-based service production seems to be on the increase.

Eligibility

We work from the assumption that gaining access to different sources of care calls for different kinds of eligibility negotiations. For the purposes of our analysis, we grouped together all those issues that the interviewees said were under negotiation when they discussed their eligibility to different sources of care. Using the tools of qualitative content analysis, we identified three main criteria in the process of negotiating eligibility to care. The first criterion is need, the most evident reason for applying for help or care. In order to receive care, people must first of all express their needs to care providers. In the case of public services, that need has to be recognized and defined normative by professionals (Bradshaw 1972). The second eligibility criterion is money. Money may be used to purchase services, and it is needed especially for market-based and grey market services. The third eligibility criterion is social relations or networks. These networks serve as channels of information and referral to different sources of care. A sense of obligation, feelings and prior engagements also come into play with social relations (Finch 1989). In informal care, social relations are the main criterion for eligibility. Our discussion below is organized around these three criteria. Rather than on the outcomes or experiences of receiving care, our emphasis is on eligibility and on how the three main criteria are negotiated. Interview excerpts are included to provide examples of how the interviewees have experienced the process of negotiation for eligibility.

Need

Anyone applying for public services must express their need for care and services either verbally or in writing. Before eligibility is granted, the professional reviewing the application will often perform needs testing by assessing the expressed need for care against the relevant criteria, rules and regulations, laws, and the institution’s resources. There are formal rules for assessing the legitimacy of the claims presented. The balance of power (cf. Strauss 1978, p. 99) in this negotiation process is asymmetrical in that the decision rests entirely with the professional, who will define whether the expressed needs entitle the applicant to receive the service. In public services, there is often only limited room for negotiation, as illustrated by the next excerpt. A Finnish man (FI7) stated about his respite care: ‘Old people’s home, there are so many people going there that getting in doesn’t just happen’. He went to a nursing home to receive respite care, not necessarily when the need arose, but when there was a vacancy in the nursing home.

Some needs testing also happens in non-profit services when they are channelled to those with the least resources, a low income and limited access to informal care. Non-profit services often serve needs that are not met in other ways (Hiatt and Jones 2000), or needs that fit the profile of the non-profit service provider. Nevertheless, eligibility is essentially based on need. The need may be continuous, but the discontinuity of non-profit services sometimes causes problems: ‘A young man [from a welfare organization] came here a couple of times and we went for a walk. But he doesn’t come here anymore’. (Finnish man FI4) Non-profit providers often rely on project-based, donation or other short-term funding as well as on volunteers, and therefore their services may be intermittent. Non-profit service providers may also be inclined to show a preference for the ‘easiest’ customers. As a result, older people may be forced to renegotiate (cf. Strauss 1978, p. 99) their eligibility, or they may be left without the service altogether.

In market-based and grey market services, elderly individuals basically define their needs themselves and buy the services that best meet their needs. This means that the negotiations take place between service provider and purchaser. However, the person in need of care is not necessarily always aware of what is best for her or him (Kremer 2006). This reflects the complexity of the issues (Strauss 1978, p. 202) negotiated. Furthermore, suitable or affordable services are not necessarily available. In market-based and grey market services, the negotiations on needs are mediated by money: the more money one has, the more needs can be satisfied.

In Italy, grey market care workers are often immigrants with inadequate language skills and with no education in social care. This may complicate the negotiations on needs and how they should be met. ‘I feel excluded … I just have to adapt to these circumstances and leave my care in the hands of a foreigner’ (an Italian woman IT13). Every detail of care work is negotiated separately since there are no formal contracts and agreements as there are in public or market-based services. A stable and formal context and guidelines for negotiations are missing (cf. Strauss 1978, p. 233). This may call for repeated negotiations on numerous and complex issues. However, the person in need of care may be dependent on grey market care, partly because the grey market is the last resort in Italy for coping at home with extensive care needs (Gori and Da Roit 2007). The stakes are therefore high for the elderly individual and the option of not negotiating may not exist at all (cf. Strauss 1978, p. 238). ‘She [the migrant carer] said I had no one to look after me and I told her not to worry about it.’ (Italian woman IT13) This excerpt demonstrates the fragility of the agreements and balance of power in the grey market, which may require almost constant renegotiation. In Finland, grey market care arrangements are apparently much less common, but there are no figures on the extent of such arrangements in Finnish elder care.

In informal care, the negotiations about needs in everyday activities are conducted directly between the person in need of care and the carer, especially when they share the same accommodation. These often implicit negotiations (cf. Strauss 1978, p. 225) on eligibility to informal care involve a large number of issues and multiple goals, since the everyday life of two individuals is at stake. Very often, these two people share a common history, and their negotiations tend to reflect feelings, prior obligations, gendered expectations, power balance and the nature of the relationship, which may be anything from affectionate to abusive (Finch and Mason 1993).

Informal care often fills in the gaps that services do not cover. Informal carers also ensure the continuity of care. A Finnish woman bound to a wheelchair told us how the need to empty her bowel does not always coincide with her home helpers’ visits. In these instances, her husband has to lift her onto the bedpan, despite the risks to his own health. The needs of the elderly and the carer are often intertwined, but as in this example what is good for one party is not necessarily so for the other. Indeed, the negotiators’ goals and interests may be opposite to each other (cf. Strauss 1978, p. 111). The negotiation process does not always proceed smoothly and harmoniously. ‘Well I don’t really need much help since my wife manages everything’ (Finnish man FI6). By making the point that he needs very little help, this man is downplaying the role and importance of the care he is receiving from his wife—a good illustration of how care is implicitly negotiated. It is also possible that the husband is not aware of all the work that the wife is doing, which includes applying for services as part of her ‘managing everything’.

To sum up, eligibility to public and non-profit services rests mainly on normative needs, and the negotiations concern the compatibility of the older person’s needs with the services offered. In public services, the legitimacy of claims (for care) is often estimated by needs or means-testing. This is particularly true in Finland where public services are quite widely used, and where the legitimacy of claims is defined in national policies. In informal care, explicit or implicit needs are negotiated in everyday encounters, and the needs and goals of the carer and the person in need of care are intertwined and sometimes at variance with one another. In market-based and grey market services, the negotiations on needs are heavily influenced by money, which we move on to discuss next.

Money

In market-based services, the older person has some freedom to decide on their own eligibility to care. ‘I went privately and paid for the tests myself.’ (Italian woman IT11) Money acts as an opening to negotiations on the services that the user wants. Market-based services are often used to supplement other service provision. Obstacles to the use of market-based services occur when the services are too expensive, when service quality is inadequate or when the services themselves do not meet the individual’s needs and goals. There is little room for negotiation on the prices of market-based services, and often the only option open to the consumer in such cases is to exit the negotiations (cf. Hirschman 1970).

In Italy, older people are usually referred to grey market services when other sources of care are not available, sufficient or affordable (Gori and Da Roit 2007). ‘I pay many different people [friends and acquaintances] because the local council can’t meet all my needs’ (Italian woman IT11). Older people and grey market care workers often have complex (cf. Strauss 1987, p. 100) negotiations on the content and costs of the service. Insufficient funds may limit or prevent the use of grey market services. The terms of care and the balance of power are determined by the elderly, as it is clear from the following example: ‘I told her [the migrant carer] to leave my house straightaway’ (Italian woman IT14). In both the grey market and market-based services, money is a vital part of the negotiations on eligibility.

In public services, the role and meaning of money is different. Since these formal services are funded or subsidized from the public purse, means testing may be applied. Indeed in Italian means-tested public services, money can be a factor that precludes eligibility, exhausting the possibility for negotiation. The fees applied to public services are fixed in advance, and there is no room for bargaining. Elder care policies to great extent determine the context for negotiations (cf. Strauss 1987, p. 233). In both countries, user charges are applied to public care services. ‘Municipal cleaning services seem quite expensive compared to our income’ (Finnish man FI7). For some, even subsidized services are too costly.

In services produced by non-profit organizations on a volunteer or charity basis, money is not usually an issue. These services are often free of charge and universally available, or limited to people with the greatest need. If the services are aimed at low income groups, money may preclude eligibility to services.

Informal care is sometimes motivated by money or some other advantage: ‘Our daughter would help us, but only if she got something out of it’ (Finnish woman FI8). Informal carers may be motivated by gaining access to income allowances or other assets of the person in need of care. Informal care may also be dictated by financial concerns in cases where institutional care is too expensive. ‘At this age I’d rather go there [residential home] straightaway… if it was cheaper’ (Italian man IT12). Access to sufficient amount of good quality care is often not at all or not the only goal for different negotiators (cf. Strauss 1978, p. 201).

In market-based and grey market services in particular, money may give the elderly some negotiation power. However, very few older people have unlimited funds at their disposal. Money can work in the exact opposite direction in public and non-profit services in that it may preclude eligibility, especially in Italy where public services are means-tested. Informal care is the only source of care where no fees apply, although money and other means of reimbursement are common in informal care, too.

Social relations

Social relations are significant in elder care in various ways. They are important channels of information, sources of peer and other support as well as sources of care and help. In many cases, the capacities and resources of older persons limit their possibilities to act as competent negotiators, and they may have at least some need for another person to negotiate their eligibility to services (Zechner 2010b). ‘I was in hospital and they thought I was a hopeless case, but my daughter works there as a nurse and she demanded that they do more tests’ (Finnish man FI4). Family members and friends may fill out applications, seek information and make arrangements. They may use their professional and other resources to insist on gaining access to services. ‘My son has now decided that I shall go there [market-based residential home] starting next Monday because he says it’s difficult for him to leave me, knowing that I’m here alone’. (Italian woman IT15) Advocacy involves the risk that the older individual is deprived of their remaining power resources (see Strauss 1978, p. 202).

Social relations are crucial in the search for grey market care workers, who are often found through friends and acquaintances. References and experiences are shared and passed on in interlinked negotiations, as it is clear from this excerpt: Researcher: ‘How did you find her (the migrant carer)?’ Interviewee: ‘Through friends. She has worked for them, so they know her well’. (Italian woman IT11) Connections are used as the grey market care work and related negotiations take place somewhere in-between the formal systems of employment and the networks of family and kin. Negotiations tend to be interconnected and often webs of favours and commitments are created (Strauss 1978, p. 131).

Care provision may be affected by social relations even when the older person is not in the position to participate in the negotiations personally. Some Finnish interviewees described how the services have just appeared as if out of nowhere: ‘When I got home from hospital, they came over to give me a check-up’. (Finnish man FI4) It is likely that while this man was in hospital, his wife or children had applied for services, thus making transactions that were invisible (Strauss 1978, p. 227) to the older person. It has been estimated that in Finland only one in three contacts to public social services are made by older people themselves (Lehtonen 2007, p. 251). Advocates of older people may on one hand hinder their participation and undermine their power in the negotiation process, but on the other hand this ensures that the needs of those who are unable or unwilling to be actively involved are also attended to (Valokivi 2008).

Social relations are relevant in accessing public services in Italy since these services are targeted to older people who do not have a family and who have a low income (Gori 2000, p. 263). People who do have close family members may be denied eligibility. In Finland, too, family members may be taken into account in needs-testing when, for example, rationing home help so that family members may have defined obligations in the service plan. Service use itself leads, of course, to social relations. Older people may become friends with public, volunteer, market-based or grey market service workers and develop a mutual sense of closeness and loyalty (cf. Karner 1998). These social relations may be useful in future negotiation situations when parties build commitments and exchange favours (Strauss 1978, p. 129, 131). On the other hand, closeness or loyalty with a care provider may prevent older people from exiting a poor quality market-based private service, even though consumers are supposed to be calculating free agents searching and negotiating for the best possible service (Vabø 2006, pp. 405). Loyalty may also prevent exit from informal care relations. It may be very difficult for carers to ignore the wishes of older people even when they are exhausted by their care duties.

Social relations are essential in informal care, which is always based on existing social ties. Grey market activities also take place outside formal structures, and therefore social connectedness is important in the negotiation process. Social relations are less important, but by no means irrelevant in negotiations concerning public and market-based services. The current trend towards the development of a care market in Finland implies an increasing number of new players in this field. This can make it harder to maintain long-lasting social ties and force older people to engage in repeated negotiations.

Care policies and negotiations

Our analysis indicated that the main criteria in negotiations concerning eligibility to different sources of care are need, money and social ties. The role and meaning of each of these criteria are different in negotiations concerning eligibility to informal care, public, market-based, non-profit and grey market services.

In public services, which have a more predominant role in Finnish than in Italian elder care policies, the main focus of negotiation is on verifying the need for care and on demonstrating the legitimacy of claims for care. The aim of the negotiations is to persuade the service provider that the applicant is indeed entitled to the service. The process often involves formal needs and/or means-testing, which means there is less scope for negotiation than in the case of other sources of care. Since public services are more important to the organization of elder care in Finland than in Italy, the process and the context of negotiation on care is accordingly more closely determined by elder care policies in Finland, and the balance of power leans towards the public sector actors (cf. Strauss 1978, p. 233). There is some Nordic evidence that the assessment of service applicants’ needs has become more standardized in public services (Rostgaard 2006, p. 456). Still, the marketization of public services, a trend which is particularly prominent in Finland, has created growing need for negotiation as older people are increasingly making choices regarding their service providers. The marketization of public services is increasing the number of players involved, and at the same time creating greater need for negotiation with more and more parties, such as service providers, care managers and market-based service producers. It remains to be seen whether there will be more re-negotiation about eligibility if older people begin to shop and bargain for the best deals in market-based services. This activity is promoted in Finland by service vouchers which may be used to purchase needs-tested public services from appointed market-based companies. In addition, a tax rebate has been introduced to encourage the direct purchase of market-based services in elder care.

The use of market-based services has been on the increase in both countries, but in Italy mainly as a result of older people buying services directly from market-based companies instead of using outsourced public services. In Italy, no specific policy tools have been designed to boost the use of market-based services. In market-based services, money is exchanged for services, but negotiations are nonetheless needed to agree on these purchases. Buying care services is very different from buying goods in that needs for care may be highly complex and constantly changing (cf. Strauss 1978, p. 100). The negotiation process is also affected by older people’s resources, the service supply and service prices.

In non-profit services, care needs are negotiated in much the same way as in public services in that the service providers tend to choose users who best fit their profile in both countries. If the target group consists of older people with a low income, money may preclude eligibility. The continuity of non-profit services may also vary and repeated negotiations may be necessary.

Grey market care has gained an increasingly prominent role in recent years in Italy, partly as a result of the cash benefit that has been introduced as a major policy tool in elder care (Da Roit 2010). The opening up of Eastern European countries has also given Italians access to a pool of cheap care workers. In grey market care, basically everything is based on negotiation: who provides the care, at what cost, how and when. There are a large number of issues that need to be negotiated and they may be extremely complex, as grey market care is often a substitute for institutional care. The stakes in negotiations on grey market care are consequently also very high (cf. Strauss 1978, pp. 99–100). Not only money but also social relations are essential in grey market care mainly due to its illicit nature. Employers and employees usually find one another through social networks. The prospects of finding affordable services are quite good in the grey market, but reliability is suspect and therefore negotiations may recur. In Finland, cash benefits are paid to informal carers based on formal agreements with the local authorities, who pay the actual benefit. In contrast to the Italian system, therefore, the Finnish carers’ allowance does not enhance the possibilities of older people to recourse to grey market care (see Zechner 2010a).

Informal care, the most prevalent form of care in both countries, relies on social exchange and negotiations are based on shared history, prior obligations and commitments, emotions, values and norms. The present policies are often designed to boost informal care. In particular, the cash benefits paid to older people (in Italy) or to informal carers (in Finland) can change the balance of power and relations of dependency in the negotiations. For example, older people may compensate the care received and carers may supplement their income, or buy services to relieve the care burden (cf. Ungerson and Yeandle 2006).

Negotiations are essential when older people are seeking to ensure eligibility to different sources of care in both Finland and Italy. Older people are increasingly responsible for organizing and negotiating their own care. Especially in Finland, this notion of self-responsibility is supported at policy level by the introduction of cash benefits, tax reliefs, vouchers and stricter means and needs-testing (Anttonen and Häikiö 2011). The change has emphasized the responsibility of individuals which is also a dominant aspect in Italian care policy. Negotiation skills and resources are increasingly vital for older people who need to gain access to the complex care system, and many of these people may face the risk of being excluded unless they are supported in the negotiation process by family members, friends or professionals. Indeed it is paramount that future policy-making on service provision takes account of the processes of negotiation on eligibility to care.

Appendix

Interviewees and their carers in Finland and in Italy

Finnish interviewees	Carers for Finnish interviewees	Italian interviewees	Carers for Italian interviewees
FI1-female, age 83	Daughter, living together, mainly using health services	IT11-female, age 83	Daughter, not living together, local district home help once a week and several grey assistants hired through networks
FI2-female, age 87	Daughter, not living together, home nursing occasionally, day center	IT12-male, age 79	Son and daughter-in-law, not living together, local district home help twice a week
FI3-male, age 77	Wife, living together, occasional home help from a carer’s association, occasionally in a nursing home when wife is exhausted, service vouchers used to buy cleaning	IT13-female, age 78	Son, not living together, local district home help twice a week, migrant carer
FI4-male, age 73	Wife, living together, uses mainly health care services	IT14-female, age 67	Friends, NGOs home help once or twice a week, migrant carers
FI5-female, age 87	Son and daughter-in-law, living with them, home help 3 times a week, day center	IT15-female, age 85	Son, not living together, home help once a week, day center
FI6-male, age 81	Wife, living at home and in a nursing home alternating every two weeks
FI7-male, age 66	Wife, living together, uses mainly health care services and nursing home occasionally when wife has some time off, children and in-laws assist
FI8-female, age 70	Husband, living together, mutual helping, both use mainly health care services, daughter only helps for money
FI9-female, age 83	Husband, living together, husband’s health also deteriorating, home help four times a day, day center
FI10-male, age 66	Wife, living at home and in a nursing home in alternating weeks, home help three times a day