Introduction
The increased number of older people in need of care and the reduced availability of family members to continue to provide informal care have led to concerns about a growing ‘care gap’ in developed countries (Organisation for Economic Co-operation and Development (OECD) 2011). Although family members still provide the bulk of care for older people (Di Rosa et al. Reference Di Rosa, Melchiorre, Luchetti and Lamura2012; Naiditch et al. Reference Naiditch, Triantafillou, Di Santo, Carretero, Hirsch Durrett, Leichsenring, Billings and Nies2013), the limited availability of formal care services and difficulties in reconciling work and caring tasks have forced households to search for alternatives – one being the employment of migrants as live-in care workers (hereafter carers) (Da Roit and Weicht Reference Da Roit and Weicht2013). A rising number of middle-class families in Southern European countries, but also in Austria and Germany, have ‘outsourced’ care tasks to privately paid live-in migrant carers often as part of informal labour markets (Bednárik, Di Santo and Leichsenring Reference Bednárik, Di Santo, Leichsenring, Leichsenring, Billings and Nies2013; Di Rosa et al. Reference Di Rosa, Melchiorre, Luchetti and Lamura2012; Di Santo and Ceruzzi Reference Di Santo and Ceruzzi2010; Simonazzi and Picchi Reference Simonazzi, Picchi, Bettio, Plantenga and Smith2013).
Privately paid assistants that provide long-term care (LTC) in private homes have come to play an increasingly important role in Austria since the 1990s when a number of private employment agencies started acting as brokers between Austrian families and comparatively low-paid carers from neighbouring Slovakia, Czech Republic and Hungary. These ‘migrant carers’ have been named ‘24-hour carers’ in the Austrian context as they often live in with the people they care for and provide round-the-clock care. They are mostly middle-aged women who previously crossed borders with tourist visas but faced highly precarious working arrangements without social insurance, legal protection or tax liabilities in Austria. Despite the difficult circumstances of these working arrangements, the increasing demand for domiciliary LTC services, lack of alternatives, significant wage differentials and high unemployment rates continued to serve as a breeding ground for this informal market (Schmid Reference Schmid, Larsen, Joost and Heid2009; Ungerson Reference Ungerson2004).
In 2007, Austria implemented a set of relatively far-reaching legal measures, which (a) formalised the status of 24-hour carers, (b) introduced subsidies for people hiring them, and (c) entailed tentative steps to ensure the quality of 24-hour care. Austria stands as an exception compared to other European countries relying on privately paid live-in migrants, since thus far no other country has implemented similar reforms and mechanisms to ensure basic quality standards in 24-hour care. Indeed, quality assurance is all the more salient as 24-hour care often takes place under a ‘double shroud of invisibility’: working in private households and often in informal labour market arrangements, leaving little room for public monitoring and supervision with particular challenges in terms of measuring, assessing and managing quality of care (Leichsenring, Nies and van der Veen Reference Leichsenring, Nies, van der Veen, Leichsenring, Billings and Nies2013).
The Austrian case thus provides an interesting case study on the extent to which the transition from an informal to a formal economy has brought about improvements in professional standards, working conditions and related quality assurance in the 24-hour care sector. While 24-hour care is an area of LTC where objective measures of relational and care quality are scarce, it is nonetheless widely acknowledged that the quality of working conditions of carers strongly relates to the quality of care as perceived by users (Patterson et al. Reference Patterson, Rick, Wood, Carroll, Balain and Booth2010). Hence, while we cannot draw any conclusions about the quality of care provided, in this paper we hypothesise positive spill-over effects of the reforms, resulting from improvements in terms of basic quality standards and in the relations between 24-hour carers, agencies and users. The results of this research are relevant not only for the Austrian context, but also for countries aiming to legalise the 24-hour care market in times of increasing shortage of labour in LTC.
Regulation of 24-hour care in Austria
In 2006, a heated public debate was set off when charges were brought against a number of people in need of care as part of an attempt to combat illegal employment arrangements with 24-hour carers. Due to the intensive media coverage, the new government raced to introduce policy measures to formalise the migrant carers' legal situation and their labour market status in July 2007 (Schmid Reference Schmid, Larsen, Joost and Heid2009). Apart from passing a new law on domiciliary assistance (called Hausbetreuungsgesetz, Federal Law Gazette 57/2008), the Austrian government amended a number of other legal stipulations to regulate the access of privately paid assistants to the Austrian labour market as well as labour and social security by-laws for employment in private households.Footnote 1 It allows for the possibility to register with the Austrian Economic Chambers as a self-employed carer (Wirtschaftskammern Österreichs 2013) or to become employed by private households or non-profit organisations (formal LTC providers). Typically, 24-hour carers work for a period of a fortnight before returning to their home country for another fortnight, during which they are replaced by another carer. Travel time is mostly not counted as working time. These biweekly shifts, as well as travel, payment and replacements, are organised by brokering agencies in Austria and/or sending countries. The majority of agencies employ 24-hour carers as self-employed carers as this offers higher flexibility in terms of working time, quantity of work and salary, as well as financial and bureaucratic advantages for the families receiving care (Bauer and Österle Reference Bauer and Österle2013; Konsument 2012; Österle, Hasl and Bauer Reference Österle, Hasl and Bauer2013). In fact, for self-employed carers no regulations on working times apply (BMASK (Ministry of Social Affairs) 2013).Footnote 2 In other words, although the reforms introduced the option to become employed with detailed regulations on permitted working times, those regulations play only a marginal role in practice.
Under the new scheme, registered, self-employed 24-hour carers pay social security contributions and thus have access to social insurance and health care services, but not to regular unemployment benefits. Self-employed carers have reported a loss of net income under the new legislation, primarily due to social security contributions and tax payments (Bauer Reference Bauer2010). To enable families to cover the increased costs associated with the legalisation of 24-hour care, beneficiaries of the Austrian LTC allowance (called Pflegegeld) can apply for a ring-fenced subsidy, albeit conditional on certain eligibility criteria.Footnote 3
In the course of the reforms, the general legislation concerning health and care professions in the formal sector was amended too. A 24-hour carer must either provide proof of theoretical knowledge corresponding to 200 hours of training, of practical experience in having provided adequate care for at least six months, or of a medical doctor or nurse delegating clearly defined tasks to them (see Bundespflegegeldgesetz, Federal Law Gazette 110/1993, §21b). In practice, however, the third option is hardly observed (Procházková, Rupp and Schmid Reference Procházková, Rupp and Schmid2008). Legislation also foresees official quality visits to randomly selected beneficiaries of public subsidies, which are carried out by the BSB (Federal Social Welfare Office). Feedback from these visits is mostly positive, thus sanctions (e.g. reductions of the subsidy) are hardly applied. According to the BSB, of the 14,199 households with a 24-hour care subsidy in late 2012, between 1,000 and 2,200 beneficiaries received these quality visits between 2009 and 2012. In July 2013, a total of 43,159 persons were registered as active 24-hour carers, the majority of whom came from Slovakia (around 70%) and Romania (around 20%).Footnote 4
With the new legislation the market of placement agencies has diversified, with more providers offering services. Placement agencies operating in the Austrian 24-hour care market can be classified into three main types: (a) ‘grey market agencies’ (Type I) including former migrant carers offering brokering services and agencies not officially registered in Austria; (b) ‘specialised agencies’ (Type II) registered as limited companies or non-profit associations that were already active before the 2007 legalisation in Austria; and finally, (c) ‘home care agencies’ (Type III) referring to large welfare organisations with a long tradition in LTC provision that, with the new legislation, started to offer their services also in the 24-hour care sector (Table 1).
Table 1. Types of brokering agencies
Approach and framework for analysis
In our analysis, we use a framework for informal markets by Beckert and Wehinger (Reference Beckert and Wehinger2013) in which informal economies are seen as one possible form of illegal markets. The advantage of this approach is that while previous frameworks are applicable only to informal markets themselves (see e.g. Portes and Haller Reference Portes, Haller, Smelser and Swedberg2005), it allows for the analysis of the functioning of both illegal (including informal markets) and legal markets, and to compare them. This is particularly useful in the context of the transition that took place in Austria in the 24-hour care sector before and after 2007. The aim is to determine whether or not the regularisation measures have addressed the (co-ordination) problems usually found in informal markets and to understand the mechanisms by which quality of working conditions, professional standards and stakeholder relationships have been enhanced. Quality assurance is therefore defined in the context of this paper as the control of compliance with legally defined professional standards to monitor and at best to prevent adverse events and to improve performance.
Beckert and Wehinger (Reference Beckert and Wehinger2013) have proposed a framework built around key problems of co-ordination in markets that arise from limitations in the scope for valuation, competition and co-operation typically found in illegal markets. We apply this framework to the Austrian situation in the 24-hour care sector, with a focus on quality assurance. Following their classification, illegal markets can be characterised by four different categories of activities: (a) provision of illegal products, (b) illegal exchange of products, (c) exchange of illegally produced or acquired goods, and (d) violation of laws in the production and distribution. Outsourcing of care from families through the employment of illicit labour, such as non-registered privately paid assistants for LTC, is one example of illegal markets covered under the fourth category. The mechanisms underlying the operation of these markets may increase flexibility of labour markets (e.g. by decreasing labour costs) yet the absence of legal stipulations may inhibit long-term productive investment and assessment of quality (Beckert and Wehinger Reference Beckert and Wehinger2013). It is thus salient to analyse and contrast legalised markets, such as the Austrian 24-hour care market after the 2007 reforms, with illegal markets by highlighting the three co-ordination problems of valuation, competition and co-operation with which market actors are confronted. The underlying assumption is that uncertainties related to market transactions need to decrease in order for all markets to operate. The framework is thus deemed valid for an evaluation of the transition of the Austrian 24-hour care market from an informal (illegal) to a formal (legalised) market.
The co-ordination problems which underlie the analysis can be described as follows (Beckert and Wehinger Reference Beckert and Wehinger2013: 12ff):
1. The first co-ordination problem in markets is valuation and refers to assigning value to a specific product and/or to signal quality. These possibilities are, however, limited under informal market structures, thus reinforcing information asymmetries between consumers and producers. Instead, middlemen, trusted by both sides, and personalised networks are used to reduce uncertainty. These issues are potentially compounded in LTC markets. Firstly, quality measurement is generally difficult, especially in home care, due to its multi-dimensional nature (Castle and Ferguson Reference Castle and Ferguson2010) and the fact that users are also co-producers of care (Baldock Reference Baldock1997). Secondly, the special characteristics of 24-hour care, taking place between families and carers without a formalised structure, render the use of agencies acting as ‘middlemen’ indispensable. This paper aims to analyse whether or not the legalisation policies of migrant carers have improved preconditions for valuation in the 24-hour care sector in Austria. In a formal market, quality assurance mechanisms should be in place to regulate access to the profession, while also ensuring certain quality standards for users and providing the basis for differentiating providers from each other. In an informal market, however, no such mechanisms are in place to guide users and ensure professional standards in the sector.
2. In formal markets, competition is regulated by law, e.g. regarding prices and quality. Competitive structures are often inefficient under illegal market conditions since consumers may face more difficulties in observing and comparing quality, in comparison with legal markets. In the absence of legal enforcement and information about quality, providers may compete on prices only, which by comparison may be easier to observe, and thus drive quality down (Dranove and Satterthwaite Reference Dranove, Satterthwaite, Culyer and Newhouse2000). With respect to this co-ordination problem, the paper aims to assess whether competitive structures akin to informal markets can be found after the regularisation of 24-hour care in Austria.
3. Finally, problems of co-operation refer to the absence of supervisory agents in illegal markets to control unscrupulous practices. The absence of enforceable contracts and information asymmetry regarding price and quality increases the importance of signals of trustworthiness by providers, and intensive monitoring by consumers. The main question related to co-operation in the analysis of markets for illicit employment is what role enforceable contracts play as opposed to personal relations and trust. Hence this paper analyses whether the formalisation of interactions between key actors in 24-hour care has changed market and working relationships.
From the above, we draw a couple of hypotheses. Firstly, we expect to find that the current system has introduced some mechanisms to improve possibilities for valuation. Secondly, we hypothesise that the diversification of brokering agencies has led to more competition after the reforms. Yet, it is unclear what effects this increased presence of brokering agencies (and carers) and increased levels of competition in the 24-hour care sector have had on quality assurance mechanisms. Finally, we hypothesise that relationships have become more formalised as a consequence of the reforms, with a positive effect also on quality assurance in terms of professional standards that can be enforced in case of violation by both users and their families, and by 24-hour carers. In sum, the analysis provided hereafter contrasts the actual functioning of the Austrian 24-hour care market after regularisation with the functioning of informal markets to evaluate whether the reforms have successfully addressed aspects of quality assurance in terms of professional standards and the improvement of working conditions, reflecting also possible improvements in care relationships.
While other studies have treated aspects of quality as perceived by users and their families (Neuhaus, Isfort and Weidner Reference Neuhaus, Isfort and Weidner2009; Walsh and Shutes Reference Walsh and Shutes2013; see also Spencer et al. Reference Spencer, Martin, Bourgeault and O'Shea2010), this paper focuses on the supply side of live-in migrant care and the ways in which the professional status and working conditions of carers are determined by agencies and the new legal situation. The empirical exploration and analysis of the situation of migrant carers, brokering agencies and public officials accounts for the different perspectives on the mechanisms that determine quality assurance in this sector.
Methods and data
This explorative study is based on a review of grey and academic literature and relevant legal documents on the 2007 policy reforms of the 24-hour care sector in Austria. This served to detail the features of the new legislation and to identify key themes to be addressed during semi-structured in-depth interviews with three groups of stakeholders: nine migrant carers, five brokering agencies operating in the sector as intermediaries between families and carers, and three key public officials involved in launching and implementing the new legislation.
Migrant carers were identified through agencies and private contacts, using purposive snowball sampling methods (Marshall Reference Marshall1996) which are frequently used sampling strategies to identify hidden and not easily accessible populations (Mack et al. Reference Mack, Woodsong, MacQueen, Guest and Namey2005: 6). In this case, they facilitated the identification of well-informed stakeholders who could potentially participate in the study. The sampling aimed to include carers who worked in the 24-hour care sector before and after 2007, and maximum variation in terms of forms of employment, origin, professional background and experience, with the latter two deemed particularly important for the study's aims. Maximum variation was only partly achieved due to the difficulties in accessing this group. Interviewees are mostly women and have very heterogeneous biographical and professional backgrounds, even if they are mostly middle-aged and of Slovak origin. All carers are self-employed and had already worked in this sector before 2007, except one (Table 2). While five out of the nine migrant carers are trained as professionals, four of them had not worked in the LTC sector before. Rather, they had either cared for a family member over a longer period of time or had only participated in the required training course of 200 hours. Those with experience working as 24-hour carers before 2007 had contacted Type I agencies in their home countries. After regularisation they also collaborated with Type II or Type III agencies. While employers of 24-hour carers were in general not included in this study, users were present in two of the nine interviews with migrant carers. In all interviews migrant carers and users gave their consent for the audio-taped interview.
Table 2. Description of sample of 24-hour carers
The five 24-hour care agencies were contacted directly and selected with the objective of maximum variation in size, type of organisation and country of operation. Three of the eight agencies contacted refused an interview, of which all were Type I agencies. Out of the five interviewed agencies one is based in Slovakia, while four agencies maintain head and/or liaison offices in both Austria and sending countries. Of these, three agencies are specialised in providing placements for carers in 24-hour care (Type II), while two are simultaneously major providers of other home care services in Austria (Type III). The size of the agencies participating in this study ranges from 100 to 600 carers being hired each year.
Public officials with prominent involvement in the legislative process leading to the measures introduced in 2007 were identified and asked to participate in expert interviews, with the opportunity to review and authorise the transcript of the interview before being published.Footnote 5
Different interview guidelines were developed for the respective target groups, piloted and validated in an initial phase of the study. Following the structure of the theoretical framework of this paper, the related interview topics for each group are summarised in Table 3. Interviews were conducted in German between April 2012 and July 2012, audio-recorded and transcribed. Data were analysed using content analysis, which called for the definition of a set of inductive categories (codes) for each interviewee group (Hsieh and Shannon Reference Hsieh and Shannon2005). The software MAXQDA supported the analysis. For this paper, interview quotations were translated into English by the authors and proofread by a bilingual native speaker.
Table 3. Hypotheses and derived themes addressed during interviews
Note : 1. The hypotheses are based on the theoretical framework of Beckert and Wehinger (Reference Beckert and Wehinger2013).
Results
Valuation and quality assurance
Moving from informal to formal structures in the Austrian 24-hour care sector has brought about an increase in initiatives to assess and manage quality. This can be attributed partly to an increase in the number of Type III agencies, i.e. conventional providers of home care which started to hire 24-hour carers only as a consequence of regulatory measures. Given the previous experience of these agencies with internal quality assurance mechanisms in home care, they started to partly apply these mechanisms to the 24-hour care sector. For example, nurses from Type III agencies carry out so-called ‘quality visits’ to check on the condition of the care recipient on a regular basis, and on the working conditions of the 24-hour carers hired. From the perspective of 24-hour carers, the interviews show that such quality visits are highly valued as a way to protect against exploitation and to feel supported.
It's something different [if there is a quality visit] than when I am alone with a family I do not know, and nobody supports me. (Carer 2)
However, quality monitoring is not carried out by all agencies in the 24-hour care sector, while at the same time systematic external monitoring mechanisms by regulators are lacking. For instance, smaller Type II agencies are usually unable to carry out visits on a regular basis. Some only do check-ups in cases of emergency, e.g. when a family member, the care recipient or the 24-hour carer calls, albeit an emergency contact point is almost always available. Most of the Type II agencies criticise the monitoring schemes of their competitors (Type III agencies) as not being equivalent to external auditing mechanisms. Only in one case is there a collaborative network being built, which entails a division of labour between an agency in charge of brokering services and a formal home care provider in charge of external quality auditing.
In the current situation, neither 24-hour carers themselves nor brokering agencies use a standardised licensing process to provide information about the range and quality of services they offer. When asked, all agencies approve of the idea of introducing a quality certificate and/or a public reporting mechanism to guide families better in choosing an agency that suits the clients' needs. It is argued that such a mechanism would also allow hospital discharge managers to recommend an agency to families based on objective criteria, rather than (randomly) choosing from a list of providers, which automatically favours well-known, larger, conventional providers (Type III agencies). One of the Type II agencies suggested specific criteria for distinguishing between agencies' services, including, for example, whether the agency's manager disposes of a care-related professional background, what kinds of services are offered and whether the agency is based in Austria. The public officials interviewed, however, do not consider the modification of the current quality assurance scheme to be necessary, given that certified nurses already visit approximately 1,000–2,200 households each year on behalf of the BSB. Summing up, some quality assurance mechanisms were introduced, yet no comprehensive mechanisms for monitoring were set up to ensure certain quality standards for users and transparency on service quality of all agencies.
Competition
With the formalisation of 24-hour care in Austria, the number of agencies operating in the Austrian care market increased from 19 in 2005 (Bachinger Reference Bachinger2009) to 133 in 2011 (Österle, Hasl and Bauer Reference Österle, Hasl and Bauer2013). The regularisation measures did not, however, affect the agencies directly, i.e. no accreditation or authorisation mechanism was introduced by law. Therefore, incomplete information about the quality of services provided by agencies and ‘their’ 24-hour carers still prevails. Care recipients and their families are unable to assess the selection processes by which 24-hour carers are hired. The only ‘objective’ measure of service quality is the qualification requirement for migrant carers, as otherwise families are not eligible for the public subsidy. These limitations in competing through quality led to a blurring of the price–quality nexus by many agencies (and consequently, the 24-hour carers they hire), driving down the prices for services in the 24-hour care market. This situation has become increasingly prevalent in recent years as 24-hour carers from Romania (and Bulgaria) joined the market. In fact, the agencies not operating in these countries are largely sceptical of the reliability of the qualifications of carers from Romania:
Any person, be he a carpenter or a bricklayer, may bring Romanian carers to Austria who work here for a pittance of €27 for 24 hours, of which then still 20 per cent is being deducted [for social security] – in fact, we had a similar case in the past. (Agency 5, Type II)
Complaints about a ‘race to the bottom’ in terms of prices are frequently made by agencies, albeit no account is made as to how far this can be attributed to the 2007 policy measures. For example, salaries for Romanian and Bulgarian carers can be as low as €30–40 (gross salary) a day, whereas Slovak carers earn around €50–70. One agency (Type II) also claims that many agencies are not registered in Austria, do not pay taxes, and are thus able to charge less than 50 per cent of the usual market price for their services, or ask for only a one-off payment from clients. In fact, yearly agency fees requested from clients are not tied to quality assurance mechanisms, and vary greatly across agencies. Differences arise partially as a consequence of the variety in services offered by different agencies. Most agencies are not only in charge of ‘matching’ care recipients and carers, but also offer replacement services in case of sickness, or guarantee a certain continuity of placements for carers. As the large majority of 24-hour carers are self-employed they would fall short of their expected income, e.g. if the care recipient has to cease care services for any reason, like a hospital stay or death. Some agencies provide some sort of protection for both 24-hour carers and families to deal with such uncertainties:
Many patients have no idea of these [additional services], as there are organisations on the market that charge [only] a one-off payment. A patient can never know or check; they [care recipients, interviewer's note] have to rely on the lists received at the hospital. (Agency 5, Type II)
The flexible price-setting should also be seen in light of the monitoring of qualifications of 24-hour carers. The criticism of agency representatives interviewed concerning the lack of monitoring is based on the assumption that some agencies accept carers with non-verified qualification documents and limited language skills. Furthermore, lower fees paid by users to agencies are also passed on in the form of lower wages to carers.
To sum up, in the absence of external quality assurance mechanisms the price–quality nexus for brokering agencies and ‘their’ 24-hour carers remains blurred. Consequently, price becomes the major criterion by which agencies (and 24-hour carers) compete with one another, with agencies expressing concerns about the implications of this situation for quality.
Co-operation
The dimension of co-operation in the Austrian 24-hour care sector primarily refers to the role of enforceable contracts as opposed to informal, personalised networks and trust – with significant effects on working conditions. Before the status of 24-hour carers became legalised, written contracts with agencies were an exception. This situation has changed considerably with the introduction of legal regulations that require a contract between the care recipient and the 24-hour carer, and between him/her and the agency. This was a source of great relief for all interviewees who had also worked under irregular conditions:
I was relieved [about the legalisation measures] because [now] I can work and breathe calmly. Before, there was a lot of stress, because of the border, because of everything; it was terrible, every time. If you worked here in 24-hour care, everyone knew it, even politicians paid a carer but it was not legal. Now it is the same [type of care], but more expensive [for the families]. I will never forget the day, when I registered and did not have to be afraid anymore. (Carer 4)
While regulations for working times of employed 24-hour carers exist, this is not the case for self-employed carers, which is the preferred form of hiring carers by agencies. In many cases, 24-hour carers report to work for periods exceeding 11 hours per day. One carer also reported that she had to agree to stay with the family for one whole year before she would be able to change positions. Moreover, the salary of self-employed carers is negotiable while wages of employed carers have the legal minimum wage as the lower bound.
The interviews with migrant carers and agencies demonstrate that trust remains an important component in the relationship between carers and families. This is due to the specific nature of the profession where the carer lives in the same household as the care recipient for two weeks every month:
One does not live one's own life [anymore] but the life of the family [where one works]. They [the carers, interviewer's note] come into the person's home as strangers. If they want to be good carers, they have to change the culture they know from home. (Carer 1)
In addition, when selecting an agency, many carers report having relied primarily on personal contacts in their country of origin. Yet, a formal application process was carried out in all cases, including a German-language test, a psychological assessment and in some cases an exam testing for knowledge of LTC, in addition to written proofs of qualifications.
Despite these guarantees, distrust still partly shapes relationships between 24-hour carers and agencies as well as families and agencies, increased by the absence of supervisory bodies that stipulate regulation of prices and services for agencies (i.e. wages, brokering fees, information distributed to carers and families):
There are different agencies, they require different fees. One agency kept €30 per month from my wage. The other required a lump sum payment of €100 when I changed the family. (Carer 3)
As for the enforcement of expected quality of services, three major stakeholder dyads can be distinguished: the relationship between 24-hour carers and brokering agencies; the relationship between care recipients and brokering agencies; and that between 24-hour carers and care recipients. For the first, 24-hour carers reported exploitation by brokering agencies before formalisation of their legal status, such as not being provided any details about the care recipient's health condition beforehand:
They told me the day before where I had to go, and I waited at the train station. The agency did not tell me anything about the family, no address. (Carer 1)
Such incidences were not reported from carers after the new regulations came into force. All receive basic information about the older person's health condition before starting to work, albeit in some cases only at very short notice. It is also possible to refuse a placement, according to carers and agencies. In fact, several representatives from agencies stressed the importance of clarifying expectations beforehand:
I tell the carer everything that is expected from her . . . and she has to tell me whether she can manage . . . Every person is different: some prefer to clean or cook, others want to do more care-related tasks. And with this background one has to decide who is the most suitable person. The family should be satisfied with the carer. (Agency 2, Type III)
As regards the relationship between care recipients and brokering agencies, the latter usually contact families to ensure that the household's condition is adequate for receiving the 24-hour carer, e.g. a separate room is available:
Clarifying the expectations of families is crucial, especially regarding structural quality such as the carer's environment. She must have a room and access to warm water, we discuss this with families . . . That is very important to me, because I have seen carers crying out of fear because of their situation. (Agency 1, Type II)
It is also common that a nurse visits the household on behalf of agencies before the arrival of a 24-hour carer, and families are asked to make a statement of preferences regarding the carer's competences. Both Type II and III agencies try to ensure the quality of their services through elaborate systems of recruitment and matching (questionnaires, needs assessments, visits and interviews).
Surprisingly, the relationship between the care recipient's family and the 24-hour carer seems to play a minor role in terms of regulation for quality assurance. That is, the agency usually handles all administrative procedures necessary for the 24-hour carer to start working. Once the carer agrees to stay with the family, most complaint procedures are also handled via the agency, as described above. Hence, the agency acts as the interface between carer and care recipient at the request either of the family or the carer in both private and professional matters.
In sum, on the one hand improvements regarding co-operation can be observed as relationships have become more formalised through contracts. That is, the 2007 regulation provides legal tools for carers and families to enforce professional standards without being as dependent on trustful relationships as before. On the other hand, feelings of mistrust partially remain in relationships between carers, families/users and agencies due to lack of clear regulations or quality assurance mechanisms on behalf of regulators.
Discussion
The changes to Austrian legislation introduced since 2007 are built around incentives offered to both suppliers and recipients in order to encourage them to emerge from their informal labour market status, or ‘moonlighting’ status, at multiple levels. Reform measures not only focused on policing and bureaucratic control mechanisms, but also on incentives and tangible subsidies for all stakeholders. This study has shown, however, that even after considerable efforts to ‘legalise’ migrant care, the sector remains a ‘grey’ area within modern labour legislation and quality assurance mechanisms, which may limit positive effects on quality of care. We argue that this is due to the very nature of personal care, the low professional status associated with care work in general and reluctance on the part of political actors to interfere with the regulation of private household activities, most notably brokering agencies active in the sector.
We hypothesised that the reforms have indeed led to improvements regarding possibilities for ‘valuation’ in 24-hour care by introducing basic quality assurance mechanisms concerning minimum professional competencies, individual contracts and professional standards. In fact, these regulations also incentivised larger agencies with established quality assurance mechanisms to enter the market. As a consequence, a more stringent selection process is applied to 24-hour carers, and some signs of improvement in terms of awareness of quality among smaller agencies are reasons for optimism as well. However, we also find our hypothesis confirmed that there is still vast under-regulation with respect to brokering agencies. This is a matter of major concern given the important role of these agencies in the matching and selection process of 24-hour carers, as well as in supporting 24-hour carers, older people with LTC needs and their families. This under-regulation is, however, partly due to the fact that the area of formal home care services also widely suffers from a lack of supervision and quality assurance mechanisms (Nies, van der Veen and Leichsenring Reference Nies, van der Veen and Leichsenring2013; OECD and European Commission 2013).
In terms of the second dimension ‘competition’, we hypothesised that the increasing number and diversification of agencies after the reforms has contributed to competition both in terms of quality and prices, even though some agencies remain unregistered and therefore are not subject to any regulations. We find that the 24-hour labour market is characterised by competition based on arbitrary price-setting by agencies and not on quality, which reflects the fact that agencies remain mostly unregulated. With new ‘competitors’ from Romania that are associated with lower wages and poorer working conditions, this situation could further deteriorate. For instance, according to a systematic review, annual fees to be paid to agencies range between €120 and more than €1,000 (Konsument 2012). Contrary to the original intentions of the legislation, the profession of 24-hour carers is still characterised by very low qualification requirements (200 hours of training). These, in many cases, could prove insufficient to ensure that the specific skills needed to care for older people with heavy care needs are mastered, including knowledge and technical expertise of the health care needs of older people as well as specialised social skills (Bednárik, Di Santo and Leichsenring Reference Bednárik, Di Santo, Leichsenring, Leichsenring, Billings and Nies2013). This downward pressure on prices and on qualification standards bears significant risks for the quality of care provided (Bauer and Österle Reference Bauer and Österle2013).
Some progress has been achieved in the dimension of ‘co-operation’ in terms of standardisation of enforceable contracts, although there is still a great deal of room for improvement, thus confirming our original hypothesis. Migrant carers and their clients can now rely on official contracts in which duration of the work relationship, salary and responsibilities are addressed. Also, the importance of mere trust in ‘middlemen’ or agencies has decreased, and reduced the psychological burden on 24-hour carers after registering with the competent authorities. This confirms results from previous studies showing that the regulation has been highly appreciated by carers, as it meant a relief not to be working under informal labour market arrangements anymore and to have access to social insurance benefits (Bauer Reference Bauer2010). Currently, a more formalised application procedure is applied in many cases, yet there are still indications that contracts continue to be violated, e.g. concerning working time and payment. Furthermore, the lack of regulation of working time for self-employed 24-hour carers endangers both the proper application of labour laws and the quality of care provided. Overall, the sector is still characterised by blurred boundaries between employment and private space, commonly found in the ‘caring economy’ and domestic work, which tends to make enforcement of labour rights more difficult (Gendera and Haidinger Reference Gendera and Haidinger2007).
Additional steps for regulation would be needed but continue to be hampered due to financial and political reasons. Migrant care is a relatively inexpensive and attractive alternative to unpaid family care and formal home care or residential facilities, though still predominantly affordable for middle-class families. It fulfils intense care needs that would otherwise require high co-payments for formal home care services, provided that these services would be available at all (Österle Reference Österle, Ranci and Pavolini2013). In addition, the concept of 24-hour care fits in with the predominant care responsibility culture in Austria in which care provided at home is the preferred LTC arrangement (Österle Reference Österle, Ranci and Pavolini2013; Weicht Reference Weicht2010). Thus, intervention in a care scheme, which remains the only affordable option to care for older relatives at home for many families, entails high political and financial risks. With quality mechanisms being still in their infancies even in other, more formalised LTC settings, quality assurance in 24-hour care would need to be further integrated in the quality development of LTC pathways across sectors and organisations, including the sensitive area of informal or ‘family’ care. Related endeavours are not only ethically and culturally sensitive (Spencer et al. Reference Spencer, Martin, Bourgeault and O'Shea2010), but by any means costly, difficult to be implemented and thus also technically complex at the beginning (Nies, van der Veen and Leichsenring Reference Nies, van der Veen and Leichsenring2013).
The Austrian policy reform that led to a formalisation of migrant care work in private households represents a unique case in Europe. Although the existence of informal markets is well known in countries that increasingly rely on live-in migrant carers, only marginal reforms to formalise these arrangements have been undertaken. Italy implemented only unsuccessful short-term solutions of amnesties for foreign workers and local initiatives of integration and training of migrant carers, whereas structural reforms to regulate the market adequately are found wanting (Del Favero Reference Del Favero2011; Di Rosa et al. Reference Di Rosa, Melchiorre, Luchetti and Lamura2012; Di Santo and Ceruzzi Reference Di Santo and Ceruzzi2010; Shutes and Chiatti Reference Shutes and Chiatti2012). Similarly, reforms in Spain focused on either immigration rules, work permits and/or on taxation (Da Roit, González Ferrer and Moreno-Fuentes Reference Da Roit, González Ferrer and Moreno-Fuentes2013; Lamura Reference Lamura, Bäcker and Heinze2013). In Germany, where around 2–3 per cent of LTC beneficiaries spend their cash benefits to employ live-in migrant carers, policy makers also mostly failed to implement comprehensive policy reforms (Theobald Reference Theobald2011).
The Austrian case, however, highlights also ethical questions arising from the variation in standards that are applied when employing private assistants from other countries as opposed to nationals. Even for the small number of employed 24-hour carers the limitation on working time of 128 hours per fortnight, heralded as an improvement in working conditions, remains higher than the working time permitted for most other professions. This entails the risk of overburdening migrant carers, especially if no sufficient respite care possibilities exist (De la Cuesta-Benjumea and Roe Reference De la Cuesta-Benjumea and Roe2014). The matter of the care drain in which significant care gaps arise in the families and LTC systems of the migrants carers' countries of origin as a direct consequence of these work arrangements must also be taken into account (Lutz and Palenga-Möllenbeck Reference Lutz and Palenga-Möllenbeck2012). It remains to be seen how far and at what pace the wage differentials between Austria and its neighbouring countries will converge and whether LTC systems in Central and Eastern European countries will expand to offer new employment opportunities in this sector. These will be decisive factors for whether or not migrant carers will remain a sustainable resource for 24-hour care in Europe and/or whether migrant carers will arrive from other, non-European Union countries.
A number of caveats should be kept in mind when interpreting the results of this study. While the in-depth interviews allowed for the collection of rich information on how 24-hour carers experienced the impact of current regulations in their work and the quality of care provided, the sample of 24-hour carers, concentrating on Slovak interviewees, is nonetheless relatively small. Although Slovak carers comprise arguably the largest group of 24-hour carers in Austria, issues around recognition of qualifications or the bi-weekly shift arrangement may be experienced differently by carers coming from further Eastern European countries. Likewise, none of the ‘grey market agencies’ (Type I) agreed to take part in the study. Further insights into the role of these agencies could be afforded by including agencies with these characteristics.
In light of political intentions to regulate migrant care work and missed opportunities ‘to develop a properly regulated care sector’ (Da Roit, González Ferrer and Moreno-Fuentes Reference Da Roit, González Ferrer and Moreno-Fuentes2013), this paper provides valuable insights on the consequences of the Austrian approach and relevant lessons for countries that aim to reform migrant care markets. The findings contribute to a better understanding of the benefits and drawbacks of the Austrian ‘migrant care worker model’ against the background of quality assurance and professional standards in the formal LTC sector as a whole. This is particularly relevant with regard to policies that address the shortage of labour as well as the irregular status of migrant carers currently experienced by many European countries.
Acknowledgements
We would like to thank the two anonymous referees for their constructive comments. We are grateful to Katharine Schulmann for linguistic editing. Also, we would like to thank all interview partners for their time and contributions. The views and opinions expressed in this paper are those of the authors who are thus also exclusively responsible for any omissions or errors. The present research was carried out in the context of the FP7 Framework Project European Care Across Borders (ECAB, Grant Agreement 242058). The funding body was not involved in designing, executing, analysing and interpreting the data presented. Andrea Schmidt and Juliane Winkelmann carried out fieldwork and analysed all interviews. All authors contributed to the study of literature, design of fieldwork, drafting the manuscript and refining the analysis. All authors approve of the version to be published.
