Giovanni Lamura leads the Centre for Socio-Economic Research on Ageing at INRCA (Istituto Nazionale di Riposo e Cura per Anziani). He graduated in economics, achieved a PhD in "Life course and social policy" at the University of Bremen (Germany), and was visiting fellow at the University of Hamburg-Eppendorf (Germany) in 2006-2007 and the European Centre for Social Welfare Policy & Research in Vienna (Austria) in 2010-2011. His research interests are focused on international research on family & long-term care; migrant care work; prevention of elder abuse; ICT-based support for informal carers; intergenerational solidarity; interdisciplinary research on ageing.

An economist by training, Giovanni Lamura has focused his entire career on socioeconomic research related with ageing, a vocational field for him. In his youth, rather than doing military service, he chose to work as a carer for elderly people in the municipality of Saltara (Pesaro, central Italy). Thirty years on from that first experience, he reflects on the current situation of dependent-care systems, whose sustainability is being thrown into question in many places in Europe.

We are facing a “care crisis” in which informal carers are ever fewer in number and have ever less availability to care for their elderly relatives. To what point is this situation concerning?

I don’t like using the term “crisis”. It sounds like something sudden and unexpected. We all knew that this situation would arrive. And in fact, the demographics are still favourable: the baby boomers are now reaching retirement age. The majority of informal carers are aged between 50 and 60 years old and are caring for their parents. Then there are the spouses, who really are people of a very advanced age. Between them they make up the largest population group, so demographically we are not facing a serious problem these days. The issue is that the tendency to lengthen working lives is putting these people under pressure.

In other words, in the near future, those who are of a working age today will be less capable of providing care because they will have to work for a longer time.

Well, in some cases it’s already happening. In Italy there was a major labour reform five years ago and the retirement age was set at 67 years. That’s very late! The same thing happens in countries in the north of Europe. But I am observing other bigger problems: the reduction of public services due to financial limitations means transferring to families responsibility for some of the care services that were traditionally provided by public care systems.

Do these same challenges occur in countries in the north and those in the south of Europe?

In the Scandinavian countries a lot more money is invested in configuring the care system. It is much more professionalised. In the past it was more residential, and now it is more focused on care at home. In the south, meanwhile, elderly people are less willing to go into a care home because there is a different concept of the home and elderly people want to remain in their own houses, even when they are not in the best of conditions.

Which means that money plays a role…

True, the Scandinavian countries invest much more in long-term care than the Mediterranean countries and those of Eastern Europe. But it is also a question of preferences and of the system’s design. In Southern Europe, and also in some countries in Central Europe such as Germany and Austria, a pattern is observed that consists of offering money to families (instead of providing services) so that they are the ones that obtain the services on their own account. So what happens then? The families resort to the “black market”.

In search of what?

Immigrant workers. Families buy a cheaper and undeclared service, because this is the only way that informal care can be affordable in some countries. It happens in Spain and Italy, for example. And many governments are turning not just one blind eye, but two to this situation, and they allow it because that is the easiest thing for them to do.

Moreover, these are workers without proper training...

That’s correct; the training of the workers and the quality of the service is another problem. Everything is related. You cannot expect well-prepared carers if you are finding them in the black market. Everything is connected: exploitation of immigrants, low quality of services and contributions that are not paid.

Faced with this scenario, which policies should be prioritised today to tackle all these problems?

In the Mediterranean countries, the issue of regulating work by undocumented immigrants should be a priority. It is not acceptable for them to become the other victims of this system. In their current situation they will have no pension, no access to the healthcare system and no unemployment benefit.

What are the problems in the north of Europe?

This matter of undocumented carers who are hired via the black market is not exclusive to the southern countries. Moreover, the Scandinavian countries are faced with the problem of the system’s sustainability. Life expectancy continues to grow, so it will be necessary to continue investing large amounts of money in prevention so that people age in an active and healthy way. Care in the long term is very costly and it remains to be seen if this level of investment can be maintained over the course of time.

So, what elements of the Nordic models could be most easily imported?

The ideal solution would be to implement a long-term care system as envisaged in the Dependency Law in Spain, for example, and at the same time demand recognition of the work of immigrant carers. It would be necessary to invest more and be very strict in controlling the money assigned to families for the care of their elderly people. In other words, I assign a benefit to you and in exchange, you must legally employ people with adequate training to certify that they are providing high-quality care services. This is the easiest route for transferring the professional services of the northern European systems to the Mediterranean countries.

What about the other way around? Do we have anything that the Nordic countries might envy?

The personal care provided by immigrant carers in Spain and Italy is something that many Nordic countries envy, especially given their extension: 24 hours per day, nights included, and in many cases six days a week. The problem with this is labour exploitation, but the reality is that this is precisely what many dependent elderly people who cannot afford a care home actually need.

What is the predominant profile among informal carers in Europe?

In the Scandinavian countries they are principally spouses. Many elderly people do not want their children to take care of them, or at least not as much as in Mediterranean countries, where there are still many children and above all daughters who take care of their parents.

Talk about the “care burden” is usually in negative terms. But is there any positive effect from taking on the burden of care?

Yes, of course there are positive effects. When somebody decides to act as a carer by their own will, generally a very solid interpersonal bond is created with the person they are helping. In addition to the affection received, benefiting somebody through care strengthens the carer’s own self-identity. I would say that this is the main positive aspect.

Yet carers receive little recognition from society...

Yes, this happens in many places, and I fear that doctors themselves have had a negative influence as they do not take into account the work of carers nor their opinions regarding the people in their care.

In your opinion, what are the formal supports that carers need in order to perform care tasks sustainably?

Firstly the carer’s role must be recognised. There should be a formal assessment at the start of the process to understand what needs carers may have, because if not they run the risk of becoming the second victims of the elderly person’s illness. Secondly, advice with the dual aim of offering opportunities for growth for carers and to relieve their work burden. Support groups are very important for carers as they enable them to meet others who are in the same situation as themselves. This helps to break with the isolation suffered by many carers, people often trapped in their homes, which they rarely leave. Carers should have their own personal lives. Thirdly, training. And finally, technologies, which also help a great deal. In reality, all these supports are interconnected.

Let’s analyse some of these aspects in more detail. What role does training play?

If you ask the carers, many of them will say: “I don’t need any training. I already know what I have to do.” But that’s not true. Just because you know how to treat some aspects of the illness, or just because you are doing what you have always done, you should not take for granted that you have nothing to learn. I am in favour of designing an initial training package that is effective for different forms of carer involvement, because it is also true that on many occasions a profile with a very high degree of professionalisation is not required for this work.

How should this training be provided?

It should be done in the least invasive way possible for the lives of carers. It is important to be aware that many will have difficulties attending training courses because they have people in their care. Thus they should be provided with occasional substitutes.

What skills should be fomented in carers?

Beyond technical questions, I believe that the most important is the ability to be respectful all the time. Because when informal care becomes a permanent habit, often care can become abuse. And one is not even aware of it. For this reason, remaining sensitive to the situation of the other person is extremely important.

Within the provision of care, what role does volunteering play?

Its usefulness depends on the organisation of the volunteers. In some places, there are very powerful associations that offer a very important support. The other side of the coin is that nobody is obliged to do volunteering, as the word itself indicates, so there is a high turnover. What I would suggest is to run campaigns aimed at young people, especially in countries affected by youth unemployment, such as Spain. I believe that it is a good idea for young people to become involved in volunteering aimed at helping the elderly, because it will help them to understand how their lives are going to end: “Look, now you are strong and you are fit, but at the end of your days this is what is going to happen to you”. It is a good life lesson.

But the reality is that the care sector is not very attractive for young people….

That is why I say that you it is necessary to invest in campaigns to raise awareness among the population and among young people in particular. I often ask myself, and I believe that we should all ask ourselves: Why is the image of care for elderly people so poor? I believe that there is an opportunity for young people to realise to what point they could be useful and necessary for someone. They can’t even imagine how much! I am convinced that care for dependency could change the lives of many young people, but unfortunately many of them consider that old age is a long way off for them.

Finally, to what point can the introduction of welfare technologies be a solution that contributes to the sustainability of care systems? What benefits and drawbacks do they have?

Technologies enable tasks to be carried out more quickly; they facilitate people being in contact, the sharing of information and even provide better work tools. But behind all of this there has to be a sensitive person, because if there is no human intermediation, then technologies alone resolve nothing.

The drawback is that they are not easy to use. And I am not referring solely to users: the main barriers to using technology in the field of elderly people are professional. Firstly, workers are worried because some technologies may represent the loss of their jobs and secondly, simply because they don’t know how to use them and also do not receive sufficient training. Many workers in the sector are not young but middle-aged people. They are reluctant to learn something new at work. This is a significant obstacle and we need to invest in training in order to overcome it.

Interview by

Juan Manuel García Campos

Journalist, La Vanguardia