State provision down, offspring's up: the reverse substitution of old-age care in Sweden

Substitution among the providers of old-age care has usually meant a process whereby the state ‘takes over’ what families used to do, but during the 1980s and 1990s, both home help and institutional care were cut back substantially in Sweden as elsewhere. Comparable, nationally representative surveys in Sweden of the provision of care for older people living in the community enable analysis of the effects of these cutbacks on the sources and patterns of care. It emerges that increased inputs from families match the decline of public services, that is, a ‘reverse’ substitution has recently been taking place. Local studies, of older people who have been followed over time as the provision of home help has changed, support these conclusions. Of the increased informal care, most has been provided by daughters, but sons have also contributed. A problematic aspect of these shifting patterns of care is that an increasing number of family carers with increasingly heavy care commitments are now without formal or informal support, whereas in the recent past many could expect their responsibilities to be shared with the state. The evidence from this study also calls into question common metaphors and assumptions about the assumed interdependence between informal care and public services for older people, and challenges the so-called substitution thesis.