Diversification of care policy measures supporting older people: towards greater flexibility for carers?

Abstract

Originally part of the private domain of families, care of the older people is now the concern of public policy. Yet, in the European context of cost containment, it is not easy to make a case for increasing public support and the caring function of families remains prominent in social policy. In this paper, the authors question public policies around care of the older people in relation to both the needs of old people, but also those of adult children, mainly women, who work and provide care for their old parents. We investigate the interactions between public support in long-term care and the caring function of families. The paper presents some results of a comparative research study based on the identification of the policy measures which have been implemented in different European countries in the sector of care of the older people, and on the detailed analysis of care arrangements set up by a sample of 86 family carers in these various national contexts. We argue that in a context of cost containment, whatever the usual patterns of care and the role given to the family and public authorities, the policy measures which have been introduced since the 90s aim to support family carers in various ways with the common objective of giving them the flexibility they need in the organisation of care arrangements, combining various resources (formal professional care, unpaid informal care, semi-formal care). Different patterns of flexibility can be identified according to the regulation of the policy measures.

Introduction

Originally part of the private domain of families, care of the older people is now the concern of public policy across a range of policy sectors: health, social work, employment, aging and the family. As stated by Daly, care is ‘a complex social good’ (Daly 2002), and in all European countries a variety of sources of care—public, private, family, and community—are combined to meet needs, within a common context of flexible boundaries, uncertain division of labour and ambiguous definitions of the caring tasks. Some authors suggest the expressions ‘social care’ and ‘welfare mix’ to describe this private/public combination (Sipila 1997; Daly and Lewis 1998; Anttonen et al. 2003). The triggers of change at policy level are complex, involving demographic trends, market participation, gender roles and individual preferences (Hakim 2000), as well as global economic changes. The participation of women in the labour market as well as the geographical mobility of families and the resulting ‘care deficit’ (Hoschild 1995) raises the crucial question of care of older people needing support. Yet, in the European context of cost containment, it is not easy to make a case for increasing public support and the caring function of families remains prominent in social policy. As stated by Leitner (2003), ‘in times with tight social budgets it seems to be a reasonable strategy for welfare states to strengthen the family in its basic caring role’ (p. 354). In this context, adult children of older parents are confronted by a wide range of responsibilities at both professional and familial levels. The issue of how to balance work and caring responsibilities appears central in the field of care of the older people, just as in that of childcare.

In this paper, the authors question public policies around care of the older people in relation to both the needs of old people, but also those of adult children, mainly women, who work and provide care for their old parents. We investigate the interactions between public support in long-term care and the caring function of families.

As in many other fields of comparative analysis of welfare states, long-term care and home-care policy have given rise to different typologies based on the welfare triad—welfare as the combination of state, market and family (Jamieson 1991; Burau et al. 2007; Anttonen and Sipila 1996; Anttonen et al. 2003; Martin and Le Bihan 2008; Da Roit and Le Bihan 2010). However, most of these attempts stress the difficulties of defining different groups of nations, since variations over time or at local level are more crucial than the characteristics which could be interpreted from a synchronic and national perspective. Analysing social care systems for ‘young and the old’ as a whole, Anttonen et al. (2003) underline the necessity of adopting a longitudinal perspective to understand the variety of both social care policies and care arrangements. They also suggest considering the consumption and production of social care together. As they state: ‘We wish to make the case that the absence of monolithic, dominant modes in the consumption and production of personal services makes it unwise to construct typologies of social care systems that are comparable to those developed in the welfare regime literature… This analytical framework builds in an idea of linear development that strongly suggests a model in which countries do not represent different types of social care but are simply at different stages along a single path of progress’ (p. 171–172).

Such an approach raises a range of crucial questions and suggests an empirical agenda: how can we discern the limits and recent developments in social care systems and policies for older people, and what directions can be identified? What might the consequences of these evolutions be for the family carers who undertake a major role in the organisation and delivery of care? Is it possible to identify a global trend in the interaction between policy measures and the constitution of care arrangements in terms of the capacity of choice for the family carers? In what sense can we say that care users and family carers are given the choice of different types of care and care providers (Glendinning 2008, 2006)?

In this paper, we propose to provide elements of an answer to these different questions by analysing care at both policy and practice levels by focusing on informal caregivers’ situation. We present some results of a comparative research study1 based on the identification of the various policy measures which have been implemented in different European countries in the sector of care for older people, and on the detailed analysis of care arrangements set up by a sample of 86 family carers in these various national contexts. We argue that in a context of cost containment, whatever the usual patterns of care and the role given to the family and public authorities, the policy measures which have been introduced since the 90s aim to support family caregivers in various ways with the common objective of giving them the flexibility they need in the organisation of care arrangements, combining various resources (formal professional care, unpaid informal care, semi-formal care).

Flexibility is defined as one important variable to extend choice for caregivers in the organisation of the care arrangements. It is a complex notion developed in different fields with several normative connotations. At the macro-level, one generally considers the links between labour market regulation, sometimes presented as constraints, and their impact on the level of informal flexibilities like grey market. At the micro-level, flexibility is considered as positive when it facilitates the individual capacity to adapt to global reconfiguration of the labour demand, or negative when it imposes exclusion and a lack of choice. But when one considers the “welfare triad” discussion, flexibility could mean something different. As Esping-Andersen stated: ‘At the macro-level, the welfare production of either of the three components [state, market and family] is obviously related to what happens in the other two. And at the micro-level, individuals’ welfare depends on how they manage to ‘package’ inputs from the three’ (Esping-Andersen 1999, p. 36). As we define it, the notion of flexibility refers to these different inputs and allows a focus, within the wide debate on choice for caregivers (Arksey and Glendinning 2007), on how public policies enable carers to put together (to ‘package’) different elements in a care arrangement. We argue that this capacity (part of the power of choice) of carers is related to the flexibility offered by care systems, which varies depending on two elements: on the one hand on the range of care resources offered by policy measures and on the other hand on how these different measures are regulated. The article suggests different (and more or less formalised) patterns of flexibility. In other words, flexibility has diverse dimensions: it can facilitate the organisation of a complex mix of resources to meet the needs of carers, but it can also mean under-regulated policy measures leading to an informal organisation of care arrangements which is not necessarily chosen by the family caregiver.

After presenting our research methodology, the first part of our paper will investigate the main characteristics of social care systems and their recent evolutions in four European countries, representing different social care regimes; from one extreme, with Italy and Portugal, where families were the principal caregivers, to the other extreme, represented by the Netherlands, where public authorities have assumed wide-ranging responsibility for social care. France constitutes an intermediate context, defined as a mixed model (Anttonen and Sipila 1996). Whatever the care model of the country, long-term care policies are characterised by a process of diversification of policy measures. This general trend cannot be considered only as a reduction of the existing gaps between the different national contexts; it also corresponds to the definition of a common portfolio of measures to meet the various needs of families. These measures, offering a wider range of care resources, give families a certain flexibility in how they organise care arrangements. In this perspective, the next part of the article will present some results from our qualitative research, focusing on the different care arrangements set up by families to meet the needs of old people, and illustrating the common range of various care resources used by families, despite some specific national features. The last section discusses the different patterns of flexibility which the diversification of policy measures offers caregivers, according to the level and type of regulation of these measures—in terms of access and monitoring of the various policy schemes—which entail different views of care work and informal care.

Research methodology

Focusing on different policies related to care towards older people in four European countries and on the care arrangements set up by a sample of working family carers, the perspective adopted in our research proposes two approaches: a detailed analysis of trajectories of policy measures and a qualitative approach to investigation of the interaction between care policies and care practices, analysed in terms of flexibility.

In view of the constant evolution of social care policies and the difficulties therefore encountered in defining national care policy profiles (Daly 2002; Anttonen et al. 2003), we consider that care regime approaches serve as a macro-theoretical framework giving an overview of long-term care in the various countries. But the changes will be grasped through the identification of the different policy measures that have been developed in the four selected national contexts. Though the 90s mark an important turning point, it can be useful to look back to the 60s in order to outline the trajectories of care policies. In reference to Daly (2002), we consider that making provision for care can be interpreted as entailing the satisfaction of (one of) three types of needs: a need for services, for time and for cash. We will focus on different types of provision for care: home-based and residential care, care leave, working adjustments and cash-for-care schemes.

Our qualitative approach is based on interviews with sons and daughters of old parents. Considering the importance of the issue of reconciling work and caring responsibilities in the sector of care for older people, and the lack of empirical data in this field (Saraceno 2010), the choice has been made to focus on middle-aged daughters and sons who are holding down a job as well as coping with care responsibilities towards an older parent. The research investigates the situations of these ‘working carers’ and analyses the interactions between work/care conciliation strategies and policy measures which have been developed in the different national settings in support of care of old people. We are aware of the strong gender dimension of this issue. Care policies are not gender neutral and care tasks are very predominantly assumed by women, formally and informally. This is the reason why, in our qualitative sample, we focus on female carers, even though we also considered 12 male carers. 17 family carers were interviewed in France, 26 in Italy, 23 in Portugal and 20 in the Netherlands. Recruited through snowballing and care services, they were selected as the ‘main carers’ of the old person: main carers are not necessarily involved in actual care tasks; they may be responsible for the organisation, monitoring and/or coordination of the care arrangements. They may or may not cohabit with the cared-for person(s) and they may live nearby, or up to 100 km away. The hypothesis was that intensity of care neither relies solely on a number of hours of care work delivered per day nor on a type of caring task, it also depends on the feeling of pressure experienced by the carers. Therefore, the main carer may not be someone who is involved in daily hands-on care, but may be someone who lives far away, who has to manage the care arrangements and who feels a significant mental burden. In order to consider this variety of conditions, the sample includes these different profiles of family caregivers. Respondents were aged 40 or over, they generally lived in a couple (with or without children), had either a full or part-time job working a minimum of 20 h per week, and reflected diverse socio-economic conditions. The persons cared for were either physically or mentally dependent and received care at home on a day-to-day basis (a few respondents had recently moved to an institution at the time of the interview).

Diversification of policy measures towards older people and diversity of care resources

Public schemes and programmes aimed at old people needing support have been implemented in European countries, including countries in Southern Europe, such as Italy and Portugal, where family solidarity has long been considered as the only source of care. The analysis of the trajectories of policies surrounding care of the older people, focusing on the identification of the main steps and turning points, shows a process of diversification of the policy measures, which is also illustrated by the diversity of the care resources mobilised by our qualitative sample of adult children carers to set up the care arrangements of their older parents.

Long-term care trajectories in the four countries

Cash payments and service provision, either institutional or home-based care, are major policy instruments developed to meet the needs of old people (Tables 1, 2). In this section, we argue that the policy trajectories of the four countries show a common evolution towards home-based care, on the one hand, and cash payments, on the other.

Table 1.

Development of services (coverage of the population aged 65+ residential care and home-care services) and cash payments in the four countries

	France	The Netherlands	Italy	Portugala
Institutions	6 %	6 %	2 %	3,8 % [3,4 % daycare centres]
Home-care services	4 %	18 %	3 %	4,9 %
Cash payment	Allocation personnalisée d’autonomie (Personal allowance for autonomy)	Persoonsgebonden budget (Personal budget)	Indennita di Accompagnamento	Complemento por dependencia (supplement for dependency)

Sources OECD, 2009

^aWall et al. 2008

Table 2.

Cash payments for old people in need of care in the four countries

	Name and recipients	Amount and criteria	Use of the benefit
France	Allocation personnalisée d’autonomie (personal allowance for autonomy) People above 60 years old	According to the level of dependency and the level of income Up to 524,84 €/month for level 4 Up to 787,26 € level 3 Up to 1049,68 € level 2 Up to 1224,63 level 1 Average amount: 494 €/month	To finance a specific care package defined by social and health professionals to employ a professional worker or a relative (except spouse) Control of the use of the benefit
The Netherlands	Persoonsgebonden budget (Personal budget) People 65 and above	According to level of dependency and level of income Hourly rates per function Average budget, 2006: € 11,500/year.	To finance a specific care package defined by social and health professionals To employ a professional worker or to pay a relative Control of the use of the benefit
Italy	Indennita di Accompagnamento Cash payment to older adults	Flat rate 480 €/month 100 % disabled	Free use No control
Portugal	Complemento por Dependencia (Supplement for dependency) Cash payment to older adults	According to the level of dependency Up to 170 €/month	Free use No control

Source Data collected by the WOUPS research team

The introduction of care services is one public answer to the needs of vulnerable old people. In the care regime typology proposed by Anttonen and Sipila (1996), it is characteristic of the ‘service led’ model, based on universal access to institutionalised or home-care services for any older people in need of care. In the Netherlands, institutional care has been financed since the 60s by a compulsory insurance plan, the AWZB (Algemene Wet Bijzondere Ziektekosten), which covers the cost of care of older and disabled people. Initially reserved for people living in an institution, this insurance has been extended to finance home-care. Since the 80s, the necessity of reducing the costs linked to institutional care has led to the development of home-care services. 18 % of over-65s receive domiciliary care in the Netherlands today (Table 1). Another evolution can be identified with the introduction of a cash-for-care scheme in the 90s, which represents a major turning point in the traditional Dutch conception of care. The PGB (Persoongebonden budget—personal budget) was introduced in 1995, giving recipients a choice between a cash allowance and services. The number of recipients rose from 5,000 in the 90s to 80,000 by 2007 (VWS 2008).

On the other hand, Italy and Portugal are generally classified in the ‘family model’ group (Wall 2007). The social policies of the two countries can be defined as fragmented and residual, and are coupled with extensive legal responsibilities to support one’s relatives. But consideration of recent evolutions in long-term care policy in the two countries shows that different paths have been taken. Italian policy is characterised by a non-evolving process—in the sense that no important reform has been introduced during the past decade (Da Roit 2010). Services, both institutional and home-care based, remain limited (Table 1) and the main measure consists of an extension to a national cash allowance—the Indennita di Accompagnamento—initially delivered to disabled people, to old people needing support, in the mid-80s. More recently, additional means-tested allowances have been implemented, (although only at a local level) in some regions and municipalities (Da Roit 2010).

Just as in Italy, until the early 80s there was little acknowledgement in Portugal of the needs of old people, who were still considered ‘disabled’ or ‘senile’, and of whom family members were expected to care for. The ‘Allowance for Assistance to a third party’ delivered to disabled people was similar to the Italian scheme extended to old people, and was renamed Complemento por Dependencia (Complementary payment for dependant people) in 1999. The difference between the two southern countries concerns the gradual emergence of the need for different types of service provisions to support home-based care arrangements in Portugal. As analysed by Wall (José and Wall 2006 and Wall et al. 2008) an initial change is visible after the revolution of 1974, with the development of day care centres, to provide care to old people living at home. In the 80s and in the 90s recognition of the need for home-care services has emerged. More recently, the 2006 National Action Plan has confirmed this evolution towards development of services. The percentage of over-65s in institutions grew from 2 to 3.8 %, and priority was gradually given to home-based services, which covered up to 4.9 % of over-65s in 2008 (Table 1). The focus on state responsibilities, though weaker than in the sector of childcare, has marked a gradual move towards welfare mix, combining a plurality of care providers. Today, the use of the cash allowance is directly linked to the development of services to deliver care to older people and therefore support family carers (Wall et al. 2008).

This is also the case in France, where a specific long-term care policy has been developed from the mid-90s, based on the introduction of a cash allowance for the over-60s (the Allocation Personnalisée d’Autonomie). Closely linked to French employment policy, with the objective of supporting new jobs in the services’ sector to reduce the unemployment rate, the implementation of this cash payment has entailed the development of professional home-based services, as the use of the allowance has been controlled by local authorities (Le Bihan and Martin 2007).

As illustrated by these national evolutions, the (re)structuring of policies towards old people is characterised by a diversification of policy instruments, sometimes bringing cash into the care system, redefining the balance between institutional and home-based care, or introducing services in countries where family was the main care provider. In this process of diversification, facilitating involvement as a family carer is another answer to the care needs of the old person. Cash allowances, which can be allocated to relatives in the different countries (except the spouse in France) can be an incentive to care for an old parent. But the qualitative research conducted in the four countries, which has focused on the specific situation of family carers who have a job and cannot be paid as full-time carers, also shows the importance of care leaves and flexible working hours (Table 3). As stated by Haynes et al. (2010), ‘an additional key challenge for policy makers is the importance of understanding the relationship between labour market participation and enabling caring activity, and how caring relationships can be better sustained by providing paid rights for career breaks to undertake caring’ (p. 81).

Table 3.

Care leaves and working adjustments in the four countries

	Care leaves	Working adjustments
France	Familial solidarity leave to accompany a dying relative. Three months, renewable once. Unpaid. In 2009, creation of a short paid leave fixed at €47/day for 3 weeks to care for a dying relative (3 weeks only).	Working time reduction (RTT): 35 h hours of work/week Possibility to work part-time
The Netherlands	Emergency leave for unexpected personal family problems 10 days’ leave/year to take care of a relative when the person is the main carer. Paid 70 % of salary. Long-term care leave: 12 unpaid weeks to take care of a very sick close relative (child, parent)	Adjustment of hours law
Italy	3 days of paid leave/month for care of a severely disabled person. The health commission has to certify that the person is 100 % disabled.	Possibility to work part-time
Portugal	15 days of unpaid leave to take care of an old parent with care needs	Possibility to work part-time

Source Data collected by the WOUPS research team

The level of care practices: care arrangements based on a diversity of care resources in the four countries

The qualitative analysis of the different care arrangements set up, confirms the diversification of policy measures leading to a variety of resources in the four countries. As illustrated in Table 4, because the focus of sample selection was on those carers responsible for the care of an older parent and working at least 20 h a week, residential care is not very well-represented.2 Home-based care is the main type of care and it is combined, particularly in Portugal and the Netherlands, with day care centre services.

Table 4.

Type of care arrangements in the four countries: institution, domiciliary care, day care centre

	France (17)	Italy (26)	Portugal (23)	The Netherlands (20)
Institutiona	3	5	0	7
Domiciliary care	13	21	17	8
Domiciliary care + day care centre	1	_	6	5

^aThe cases where in institution when the interview was made but the focus was on the trajectory of care, before institution

Each national data set shows a combination of different resources in addition to the family carer, who cannot bear the full burden of care alone. A housecleaner, a paid care worker, professional or not, a nurse, a sibling, a friend, or a neighbour who delivers informal care, a day care centre: all of these are used in the different countries to organise the old person’s home-based care, constituting a veritable mosaic of various care providers according to the availability of the informal carer, the needs of the old person and existing public or private professional support. Though the sample confirms the emphasis on public services in the Netherlands, it shows that externalisation of the caring tasks outside the household and even outside the family network is also a main feature of the care arrangements in the other countries (Table 5). Even in a country like Portugal, where intergenerational solidarity remains strong, with the co-residence of two and even three generations in the same households—three cases of care provided by the family carer alone and eight cases of care delivered by the family—delegation of the caring tasks to paid carers outside the family and even to professional services is significant in the sample studied (12 cases). In Italy, the outsourcing of caring tasks appears specific, with the recruitment of migrant carers rather than professional workers (13 cases of migrant carers, 5 paid non-professional and 4 professional workers only).

Table 5.

Type of externalisation of care in the four European countries (exclusion of the cases in institution)

	France	Italy (23)	Portugal (23)	The Netherlands (13)
Main care giver and no externalisation	0	0	3	0
Externalisation to family members only (spouse, sibling, children of the carer…)	0	1	8	0
Externalisation of part of the caring tasks to paid non-professional and/or professional carer (at home or day care centres)	16	21 [13 cases: migrant carers 5 cases: paid non prof. 4 cases: prof. services only]	12 [4 cases: paid non professional 5 cases: paid professional services 3 cases: multiple delegation]	13 [5 cases: home care services + day care centre 8 cases: home care services]

Source Data collected by WOUPS research team

The resort to these various forms of care resources confirms the idea suggested by Ungerson (2005a, b) or Geissler and Pfau-Effinger (2005) of a blurring of boundaries between the usual categories of care: informal and formal, paid and unpaid. Cash transfers to families and the possibility of paying non-professional carers outside or within the family have introduced new hybrid forms of paid work, defined as ‘informal care employment’ by Geissler and Pfau-Effinger (2005). Besides, though diversity of care resources introduces flexibility for the caregiver who can combine various resources to meet the needs of the old person, it does not mean that all resources are equivalent. What about the so-called ‘professional’ care workers? What is the reality of care behind this common trend? In our sample, a main difference concerns the number of professional hours delivered: the analysis of the 86 care arrangements show that, although the Dutch system can provide professional care every day if needed, this is not the case in Italy, where professional services are insufficient and can only deliver a complement of 2–3 h per week. The four Italian cases with professional services only cover needs where the dependency level is not too high and the needs not too great. Though service provision seems more significant in France, in most situations, it represents between 5 and 10 h a week and appears to be only one component of the French care arrangement. Although diversification in how care is delivered is common to all systems of care for the older people and—thanks to the range of care resources on offer—contributes to the flexibility given to the family in their organisation of care arrangements, the regulation of care delivery mechanisms varies from one country to another, thus introducing different patterns of flexibility.

Discussion: various patterns of flexibility

The flexibility offered by the range of care resources takes different forms, depending on how stringently the different public schemes are regulated. Three patterns of flexibility can be identified, taking into account both the current situation and the orientation taken by the care systems: a formalised flexibility, represented by the Netherlands, where allowances as well as care leaves and working adjustments are well-regulated and integrated within both care and labour market practices. At the opposite end of the spectrum is informal flexibility, represented by Italy, where care arrangements rely on informal organisation and negotiation, leading to more unpredictable care arrangements. In between, France—and to a lesser degree Portugal—constitute an intermediate situation of semi-formal flexibility, with an evolution towards professionalization of services in Portugal, and a strongly regulated cash-for-care scheme in France, but poorer provision for working adjustments or care leave, which entails informal practices (informal negotiation with employers and colleagues to free time for care).

Different cash-for-care rationales and regulations

Given that policy trajectories are different, the stated objectives of cash allowances may appear contradictory (Da Roit and Le Bihan 2010). In the Netherlands, the introduction of cash-for-care was an explicit means of making the existing long-term care system, which was exclusively based on services, more flexible by reintroducing family as carers (Grootegoed et al. 2010). The objective was to recognise the autonomy of the families (Glendinning 2006) and respond to their desire to be more active in the organisation of care arrangements, by letting them choose the carers—professional or non-professional—delivering care to their older parents. On the other hand, in France, Italy and Portugal, where care of old people relied mainly on informal care, the introduction of a cash for care scheme can be defined as a direct support for family carers, for whom it becomes possible to outsource part of the caring tasks by recruiting a carer outside the household and family.

Cash-for-care schemes also differ in their specific regulations with regard to eligibility rules (means-tested and/or needs-tested), use of cash allowances and the kind of working relations promoted by the different schemes (Ungerson 2005a, b, 2007; Da Roit and Le Bihan 2010). Regarding monitoring of the benefit, Da Roit and Le Bihan (2010) have identified two different models—regulated and unregulated. France and the Netherlands have tighter regulation than Portugal and Italy. The benefit is meant to finance a specific care package—defined as a number of hours per type of care—according to the recipient’s needs as defined and assessed by the local social services system or the administration of the local authority. Flexibility given by the cash allowance—qualified as formalised flexibility—lies in the right to choose one’s home help, who may be a professional or a relative (with the exception of the spouse, in France). Use of the benefit is strictly controlled and recipients have to justify their expenses. In contrast, in Italy and Portugal, recipients are free to spend their benefits as they wish, no care package is defined, and no administrative monitoring is organised. In addition, the way in which the benefit is controlled in France and the Netherlands has affected the organisation of care work: even though users can choose their carer, the latter must be officially recruited. This process of formalisation of previously informal (paid or unpaid) care does not exist in the two southern countries, where the cash allowances appear to be an income supplement for the family.

The impact of both regulated and unregulated schemes is closely linked to features of the care market. As illustrated by the care arrangements in our sample, in Italy, where the use of the cash allowance is not controlled, a grey market in care has progressively emerged. According to recent estimates, there are currently between 650,000 and 800,000 immigrant care workers in Italy. Even if the unregulated Italian cash payment has not been the direct ‘cause’ of the rise of this grey market, it has certainly supported its development (Da Roit and Castegnaro 2004; Da Roit and Facchini 2010). As reported by the interviewees, these badenti (meaning ‘people who watch over, look after’), who live with the old person, ‘do a bit of everything’ and ‘keep an eye’ on the old person. They are asked to perform a variety of tasks ranging from personal care to domestic chores. By contrast, in the Netherlands (where it has been significant), and also in France and Portugal (where it is more recent and introduces a semi-formal flexibility), the development of a qualified professional care market can lead families to turn to professional social services or to formalise previously informal care through an employment contract.

Formalised flexibility in France and the Netherlands also means professional support for families. Indeed, in both countries, informal family carers who apply for the benefit have social and administrative interlocutors they have to consult, and who will help them organise and adjust care arrangements, which is a better guarantee of quality. Conversely, in Italy, where flexibility can be defined as informal flexibility (with weak regulation of the cash allowance) the main family carer is isolated and has a significant management role: recruiting, supervising and (usually) paying the migrant worker. This person also has to stand in for the badente when she is absent, and face unpredictable events alone. The situation can be very difficult when the badente suddenly decides to leave. Moreover, the quality of the care delivered can be questionable, as can the working conditions of the migrant carers (Da Roit 2010).

This formal/informal dimension of flexibility must also be analysed through the regulation of care leaves and measures relating to flexible working, which have been introduced in the four countries and aim to facilitate the involvement of family carers.

Regulation of care leaves and working adjustments

Though they exist in all the countries studied (Table 3), care leaves do not have the same impact on users, as they can be specifically for care of the older people or not, paid or unpaid, long- or short-term. Unsurprisingly, the Netherlands has a strongly formalised leave system (Grootegoed et al. 2010) which confirms the formalised dimension of the flexibility introduced by the cash payment. Employed carers are entitled to emergency leave for unexpected personal family problems, short-term leave to care for a relative as a main carer and long-term leave—unpaid—when caring for a seriously ill child, partner or parent whose life is at risk. Though the latter is unpaid, the Life Course Saving Scheme introduced in 2006 enables workers to save money in order to finance their leave. Some measures have also been developed in the other countries but these seem limited in comparison with the Dutch system. In Portugal, the 15 days per year of care leave is unpaid, which does not encourage carers to use it. On top of 3 months’ unpaid leave, France has recently introduced a 3-week period of paid leave. But the payment remains low (€50 per day) and concerns only end-of-life care of an old parent. Finally, in Italy, though the poor range of care services and the low amount of cash payments displays the dearth of resources in the sector of care for older people, the monthly paid care leave (3 days per month) proposed to family carers of a severely disabled relative, is a primary solution for balancing work and care responsibilities, widely used by the Italian carers in our research sample (Da Roit and Naldini 2011). This is particularly useful when making hospital or GP appointments, or when having to leave work to deal with an emergency. Yet, considering the various policy measures—the poor range of services and the low amount of the unregulated cash payment—and the fact that care leave aims at facilitating informal care provided by family members—the flexibility of the care system remains geared towards informal care solutions.

Flexible working practices, which are another type of policy measure to support employed carers, also differ markedly across the four countries. Once again formalisation of such flexibility is a key feature of the Dutch employment system (Knijn 2001; Knijn and Da Roit 2008). Since 2000, the Adjustment of Hours law supports Dutch working carers, by giving them the right to increase or reduce their working hours, working full-time at the beginning of their career, and part-time when they have young children or old parents with care needs. Although part-time working regulation has also been developed—to a greater or lesser degree—in the other countries studied, its introduction remains timid, difficult to apply and to accept for employers, and source of strong gender inequalities, as is shown by our sample of working carers in the four countries: it must be noted that whereas the Dutch carers of the sample work part-time or have a light full-time workload of 36 h per week, full-time work is the predominant configuration in the other countries. However, and as confirmed by the working carers interviewed in France, the introduction of ‘RTT’ (Réduction du Temps de Travail—reduced working hours) in 1998, has contributed to facilitate the work/life balance for parents of young children as well as that of adult children caring for an old parent by reducing the numbers of hours in the working week from 39 to 35, or by allocating specific RTT days off to employees (Pailhé and Solaz 2009).

Conclusion

Analysis of the interaction between policy measures and care practices at family level has shown a process of diversification in the four countries, through the development of schemes such as cash allowances, care leaves and care services. Two main consequences have been identified: the shifts in the usual patterns of care based on the welfare triad and the development of flexibility offered to family carers in the organisation of care arrangements.

Though care models constitute a macro-level framework, the analysis at the level of policy measures questions the usual distinction between family model and service-led models. The gradual introduction of care services in a country like Portugal to complement intergenerational support, shows that an evolution is underway. Conversely, in a country like the Netherlands, the development of a cash-for-care scheme has reintroduced the family as a main care provider. In all the national configurations studied in this paper, the context of cost containment and the difficulty in developing public support has brought the focus back on to the family (Ungerson 2005b). Public measures—in cash, services or time—can therefore be analysed as a way to support families in their caring function.

Considering this general context of (re)familialism, flexibility offered to the family carers in the organisation of mixed care arrangements, combining different types of formal and informal care, appears as a main objective of policy measures. Although this is revealed to be a common trend in the four countries, different patterns of flexibility are identified, according to the frameworks and characteristics of the different public schemes introduced, ranging from the formalised flexibility characteristic of the Netherlands to the informal flexibility promoted by public policies in Italy.