Archive

Margareta Lindelof looks at recent changes made in community care in parts of Sweden where district nurses have taken over from home care managers trained in social work

The traditional way of organising home care for older and disabled people in Sweden was to provide service through home care managers. This led to an integrated leadership role.

However, during the 1990s a change took place in most municipalities and the role of the home care manager is now divided into two specialised professional roles. One role has responsibility for the programme, staff and budget, the other for the needs assessment only. This was, and still is, part of a trend towards privatising care for older people.

However, neither of these organisational approaches is reflected in the system in Sundsvall. Here, district nurses have replaced home care managers from social work backgrounds and within a very short time a medical culture has started to arise in community care.

The new home care managers have responsibility for both medical and social care among older and disabled people within their area. They are responsible for the work, supervision and administration of the home carers. A home care manager carries out a needs assessment as soon as someone applies for community care. This focuses on social matters and is separate from medical assessments and decisions - although the district nurses will also look after the medical needs of older and disabled people.

By the end of 2001, there were about 50 district nurses (who have been required to study social care legislation) working as home care managers in Sundsvall. Among the home carers there are an additional 30 nurses. This shows the extent to which the medical culture has permeated the organisation.

The most important gains of this medicalisation have been to the elderly and the disabled, who only need to contact or deal with one single profession, regardless of whether it is a medical or social problem. Similarly, the home carers only have to meet and co-operate with one professional instead of two - home care manager and district nurse.

On the other hand, a medically well-educated district nurse has to spend a lot of time and energy on administration, which begs the question whether this is the most effective way of using a medical professional. Compared with other municipalities it seems that the medicalisation model can be a very expensive way of organising elderly care.

One must bear in mind that only 15 per cent of the needs and the care of older people are medical. The primary task is social. Also, there is a problem recruiting new home care managers. The education system does not offer joint medical and social competence. Neither can social workers from the ordinary education system be recruited as home care managers. In the long run, it is a worry that the social perspective may be lost in this kind of organisation.

However, we now have a professional role that includes at least two different professions - health and social work - based on different legislation. This dual role may result in social aspects of care becoming secondary to medical care.

Margareta Lindelof is a social issues investigator working for social services in Sundsvall

Background

l Sweden (Sverige) covers nearly 450,000 sq km (nearly twice the size of the UK) and has a population of 8.9 million.

l Almost 19 per cent of the population is 65 years and over, of which 7.6 per cent receive home care services and 8 per cent live in special accommodation. The local councils (kommun) have responsibility for social services, and county governments (landsting) have responsibility for health and medical care.

l Ethnic groups: Swedes with Finnish and Lapp (Sami) minorities.

l Sundsvall is a municipality on the east coast of mid-Sweden with a population of about 95,000. Almost 18 per cent of the population are 65 years and older, of which 7 per cent receive home care services and 7.5 percent live in special accommodation. In Sundsvall the kommun has responsibility for health and medical care up to the level of district nurses.