Contested Professionalism Payments for Care and the Quality of Home Care

• Published date: 01 July 2007
• Author: Trudie Knijn,Stijn Verhagen
• Date: 01 July 2007
• DOI: 10.1177/0095399707300520
• Subject Matter: Articles

Contested Professionalism

Payments for Care and the

Quality of Home Care

Trudie Knijn

Utrecht University, Netherlands

Stijn Verhagen

Council for Social Development, The Hauge, Netherlands

In the recent past, policy makers have emphasized the benefits and positive

aspects of direct payments for care of frail elderly people. In this article, the

authors present the theoretical framework of “struggling logics of home care,”

by means of which they explore the underlying logics of the introduction of

payments for care: market, family, and state. More specifically, the authors

show the strengths and weaknesses of a fourth logic—professionalism—and

expound how this logic is submitted to marketized and familialized payments

for care. The authors conclude that there are indeed some positive aspects of

the trend toward payments for care. However, (female) professional home

care workers benefit hardly at all. On the long term, this could also erode the

quality of care provided to recipients.

Keywords: home care; payments for care; logics of care; professionalism;

welfare state; the Netherlands

“If provision is sub-standard, the right to care becomes an empty con-

cept, and care services will be unable to pay for themselves. Care is

not a market good because it too closely concerns the most intimate needs

of human beings.” Bettio and Prechal (1998, p. 43) make this straight state-

ment in the report Care in Europe, in which they map out care provisions

and regulations for children and elderly people on behalf of the European

Commission. Obviously, few will deny that substandard care is unmindful,

and hardly anyone is prepared to pay for low-quality care. Yet an intriguing

question remains unanswered: How is one to evaluate the quality of care,

and what are the basic assumptions or “logics” behind pronouncements on

substandard care?

In this article, the authors focus on social policy on care for frail elderly

people. An aging population results in increasing numbers of frail elderly

Administration & Society

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July 2007 451-475

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451

individuals in need of care, which is a major challenge to the maintenance

of intergenerational solidarity. Already today, 16% of the population con-

sists of people age 65 and older, increasing to 30% by 2050 (Eurostat,

2004). National governments introduce payments for care as a high-potential

arrangement to improve user choice, to satisfy clients’ wishes for auton-

omy, and to reach cost efficiency all over Europe. We will analyze the

meaning of these arrangements and their implications for the quality of pro-

fessional home care.

To understand what it means if payments for care become the favorite

solution for elderly care, we present an ideal-typical framework: the strug-

gling logics of home care. Payments for care imply the replacement of the

bureaucratic-professional supply of home care by a privatized (by way of

family and market), demand-led provision of home care. Our ideal-typical

framework makes visible in what respects professionalism competes with the

logic of the market and the family and helps us understand why and how pro-

fessionalism in home care relates to an alliance of marketization and famil-

ialization. “Logics” or “ideal types” offer us a methodological framework to

confront reality with a theoretical and abstract scheme. Because the provision

of care by private (family, market) and public (profession, state) institutions

can often be seen as illogical, atypical, or irrational, our ideal types serve as

rational measuring lines, therefore contributing to a better understanding of

the predominantly irrational reality (cf. Weber, 1904/1971).

The article first maps out various forms of care for frail elderly people

in European countries, explaining how publicly provided professional

home care tends to become replaced by various forms of payments for care.

We illustrate this with the recent introduction of personal budgets in the

Netherlands. Next, we introduce a theoretical, ideal-typical exploration of

the logics of the state, the market, and the family on one hand and the logic of

professionalism on the other. This sets a path for the discussion on contested

professionalism, regarding in particular a “weak” (female) profession such

as home care. Although there are good arguments for payments for care,1

we conclude that their introduction has major implications for the rights

and needs of professional care workers. In the long-term this could also

erode the quality of care provided to recipients.

Payments for Care

Home care for frail elderly people developed in the postwar period into

a professional albeit low-skilled service. What home care exactly comprises

varies per country but in any case includes domestic care (cooking, cleaning,

452 Administration & Society