Population Ageing

https://doi.org/10.1007/s12062-017-9215-1

Between User’s Expectations and Provider’s Quality

of Work: the Future of Elderly Care in Lithuania

I. Blažienė 1 & L. Žalimienė 2

Received: 29 March 2017 / Accepted: 14 December 2017

# Springer Science+Business Media B.V., part of Springer Nature 2017

Abstract In the context of the future development of a high-quality, user-driven

elderly care system and efforts to ensure sufficient labour supply and job quality in
this sector, it is important to analyse the sector from the perspective of both service
users and service providers. The article aims to reveal the controversy between the
demand for eldercare services, which reflects preference for informal care and home
help services, and the challenge of securing quality jobs for care sector’s employees.
Expectations of potential service users with regard to care services in Lithuania indicate
a need for developing various employment models, including non-standard forms of
employment, in order to ensure better access for the elderly to in-home services. On the
other hand, taking into account the problem of the quality of jobs, the article considers
not only the preconditions for developing the service system itself, but also the issues of
job quality within the sector.

Keywords Elderly care . User’s expectations . Service provision models/employment

models . Job quality

Introduction

Rapid population ageing in Europe requires a plan for future reforms that will be
necessary in the eldercare sector which involves preparation for the reforms by shaping
appropriate policy directions in care and employment. Skilled and lower paid care work
has been observed to expand with population ageing (Goos and Mannin 2007), and this
is likely to be one of the reasons for labour deficit in the sector. The shortage of workers
in the social care sector is determined by unattractive working conditions within the

* I. Blažienė
inga.blaziene@dsti.lt

1
Lithuanian Social Research Centre, Vilnius, Lithuania
2
Vilnius University, Vilnius, Lithuania
 I. Blažienė, L. Žalimienė

sector and the declining number of families ready to provide informal care (European
Commission 2014). Analysis of the research and studies carried out provides a clear
indication of the prevailing view in European countries that social and health care
systems have to function in such a way as to enable people live in their own homes for
as long as possible (Tarricone and Tsouros 2008) and that the best choice of eldercare is
in-home services provided by professional home helpers or informal caregivers, for
example, children (Genet et al. 2013). On the other hand, attention is paid to home help
workforce being fragmentary and difficult to organise (Lethbridge 2011); labour
turnover is a major problem in the sector (Holmes 2016). In order to reduce the
shortage of workforce within the home help sector, it is important to make home help
jobs more attractive (Morris 2009). However, changes in service provision models can
develop in the opposite direction. For example, the so-called cash-for-care (direct
payments) model, which was created to include market mechanisms into the social
care sector to increase choice for service users, appears to be gaining popularity in
European countries (Macdonald and Charlesworth 2016). From the perspective of
service providers, however, this model also means the expansion of non-standard forms
of employment (including self-employment) and hence lower quality of jobs and worse
working conditions for the employees. Therefore, the planning of the development of
elderly care services in the future should be based on a dual perspective which involves
demand-based development of infrastructure, on the one hand, and the improvement of
the quality of jobs in the sector in order to attract and retain the workforce necessary to
provide elderly care services, on the other hand.
There are several current social and demographic factors in Lithuania that should be
mentioned for their importance in terms of influence on eldercare development in the
future. The most relevant issues include the problem of emigration, changes in the
family structure and female employment. Lithuania has been experiencing intense
migration outflows for many years. According to Statistics Lithuania, around 20% of
the country’s population have migrated from the country since 2000, demonstrating a
particularly high level of emigration among young people: persons aged 20–29 account
for approx. 35% of total emigrants, while persons aged 15–29 make up even 42% of
total emigrants (Eurostat, Emigration 2017b). Changes in the family structure also
indicate fewer opportunities for the elderly to expect care from the family (spouses,
children). The high divorce rate reflects the rising prevalence of the single-parent
family model. Eurostat figures show that Lithuania had 44.3 divorces per 100 marriages
(Eurostat, Divorce indicators 2017a) in 2014 and 27.7% of live births outside marriage
(Eurostat, Share of live births outside marriage 2017c) in 2015. Although standing
above the EU average, fertility rate in Lithuania is also low (according to Eurostat, the
total fertility rate in Lithuania in 2015 was 1.70, in the EU – 1.58) (Eurostat, Total
fertility rate 2017d). One more reason making it difficult to ensure involvement of the
family in caring for other family members is the high level of female employment in
Lithuania. According to Eurostat figures, in 2015, the female employment rate in
Lithuania for age group 15–64 was 66.5% (EU-28 – 60.4%), showing a 5.5 percentage
point increase from 2000 to 2015 (from 61.0%. up to 66.5%) (Eurostat, Employment
rates by sex, age and citizenship 2017e). Therefore, the social-demographic trends
prevailing in the country are indicative of a decreasing access to family care in the
future. In this light, it is necessary to favour those willing to engage into the aforemen-
tioned activities and facilitate their involvement.
Between User’s Expectations and Provider’s Quality of Work: the...

In Lithuania, residential care services account for a high proportion of services in the
elderly care sector, with a number of huge care homes for the elderly built in Soviet
times. According to Statistics Lithuania, from 2005 to 2015, the number of recipients of
residential care services in the country grew by 31% and the number of those receiving
home help services increased by 3.5 times. Even though home help services have been
growing at an accelerated pace since 2006, comparison of coverage of such services
demonstrates that Lithuania is still significantly behind many EU countries (Rauch
2007). By comparison, in 2000 only 0.85% and in 2015 only 2.6% of the total
Lithuanian population aged 65+ received help at home and 0.98% and 1.1%, respec-
tively, were recipients of residential care (Statistics Lithuania 2017). Moreover, home
help services are underdeveloped and there is a clear predominance of informal care for
family members, which has almost no support from the state (Lazutka et al. 2015). It
means that informal eldercare-givers receive no transfer payments, there are no
favourable conditions to employ private individuals for providing home help services
and the use of respite care services (introduced in 2007) is very low among carers. In
Lithuania, the possibility for users to receive direct payments to buy services (Bcash for
care^) was introduced as early as in 1996. However, this instrument has low prevalence
in practice. According to Statistics Lithuania, in 2000, cash for help was paid to 786
persons and only to 113 persons in 2015. Yet, findings from the studies carried out in
other countries show that recipients of cash for care are more frequently satisfied with
services as they are able to choose whom to hire as service providers (Zarb and Nadash
1994). On the other hand, individual hiring of service providers means non-standard
forms of employment, and trade unions see some problems in the welfare issues of this
type of workers (Dowson 2002).
Although separate elements of eldercare in Lithuania are frequent topics of research
(e.g., pension policy, level of income of the elderly (Skučienė et al. 2015); peculiarities
of organising home help services (Kuznecovienė and Naujanienė 2015); professional
well-being of care sector workers (Žalimienė et al. 2013), there is a lack of research
addressing the development of the eldercare system from the perspective of both
service users and service providers. The lack of such integrated knowledge leads to
one-sided forecasts about the development needs of elderly care services, covering only
the development of service infrastructure or only the problems relating to labour force
demand. This article, therefore, aims to look at the system of care services for the
elderly from a dual point of view, namely with regard to the development of the
infrastructure of services, and with regard to the diversity of employment models and
improvement of job quality within the sector. To achieve the aim, the main tasks have
been set as follow: to analyse expectations of people aged 50–65, as potential users of
elderly care services; to define the current organisational models of in-home elderly
care existing within the sector and their perspectives; to characterise the quality of jobs
of persons working as providers of care services at home.

Theoretical Framework

The elderly care sector is analysed in this article from the perspective of users’
expectations for services, on the one hand, and from the perspective of organisational
models of elderly care at home and job quality inherent for these models, on the other
 I. Blažienė, L. Žalimienė

hand. The parallel analysis of the two perspectives enables an evaluation of changes
brought about by developing services in the direction of users’ expectations on the
service models and the quality of jobs related thereto.
Expectations are a certain type of beliefs, perception of future events and can,
therefore, serve as a basis for providing insights on the future (Borup et al. 2006). In
addition, expectations might shape certain behaviours, while met user expectations of
services lead to increased satisfaction therewith (Bowling et al. 2012). This suggests
that analysis of expectations may provide answers as to what services will be preferred
by the future older population. Expectations are a multidimensional phenomenon,
complex beliefs or values, influenced by past experiences (Linder-Pelz 1982), or
Bsocially endorsed^ (Thompson and Sunol 1995). For example, expectations that
children will care for ageing parents could be related to strong family care traditions.
Service users have a set of expectations and priorities about services that would be the
most beneficial for them in the future (Levin and Milgrom 2004). Researchers claim
that expectations toward care provided are personal perspectives that vary from person
to person (Allan B. de Guzman et al. 2012), or that expectations are influenced by both
personal and social factors such as values, information possessed, interests, social
standards, roles, etc. Expectations are also contingent on the contexts within which
activities take place and relations develop. Researchers distinguish between four types
of expectations: ideal (referred to as an aspiration and desire); predicted (described as
realistic, based on practical experience); normative (influenced by social norms); and
unformed (users are unwilling or unable to articulate their expectations) (Thompson
and Sunol 1995).
The circumstances above led to the assumption used in this article that expec-
tations of 50–65 year-old adults would reflect the peculiarities of the need for
elderly care services in the nearest 20 years. Inclusion of younger individuals into
the research would be less sensible due to the rapidly changing environment and
likely influence thereof on the choice of future users (e.g., currently, residential
care facilities for the elderly are viewed as care institutions for old people
abandoned by their families. However, this attitude may be different among young
people due to the weakening of relations between generations, etc.). Opinions of
50–65 year-old adults were analysed by reference to the above-mentioned typol-
ogy of expectations cited by Thompson and Sunol (1995). Ideal care expectations
in the research were operationally defined as expectations of respondents who
reported having no personal experience of elderly care, while expectations of
those with personal experience of elderly care were categorised in the research
as predicted expectations. Expectations of respondents supporting the statement
that adult children should be always responsible for their elderly parents’ care fell
under normative expectations. In addition, one more type of expectations - modern
expectations – was created for the analysis of research data and was defined as
expectations of respondents who did not support the traditional views regarding
children’s responsibility for caring for their elderly parents.
Elderly care services from the provider perspective are analysed in the article by
adopting a total social organisation of labour (TSOL) approach (Glucksmann 2005)
and the job quality concept. The TSOL approach allows viewing labour as a multiple
process existing both on the market and beyond it, covering formal and informal
employment, paid and unpaid labour.
Between User’s Expectations and Provider’s Quality of Work: the...

According to the TSOL and a multi-layered conceptual framework introduced by

Williams C.C. (Williams 2010), labour practices are situated Balong a spectrum from
relatively market-oriented to more non-market-oriented […], from non-monetised […]
to monetised labour^. This framework is especially relevant with regard to home care
services, where actually all forms of market/non-market and monetised/non-monetised
labour practices are used.
With population ageing, the informal care sector (unwaged family, community,
relative carers, etc.) becomes an important resource for the development of home help
services for the elderly. On the other hand, users themselves often give priority to
informal care thus urging to delve into the possibilities for informal care development.
It is argued that the emerging new forms of work, primarily provision of home care
services, implies a decline in job quality – standards created under the standardised
employment relations would be difficult to maintain in a world of individualised,
flexible and non-standard working arrangements (Dahl et al. 2009).

Methodology of Empirical Research

This article relies upon the findings of empirical research on expectations of Lithuanian
residents. A representative questionnaire survey of Lithuanian residents aged 50–65
was carried out in 2015–2016 to find out what types of care services are expected and
desired in old age. A total of 1205 respondents participated in the survey representing
opinion of this age group in Lithuania (errors for the results do not exceed 2.8% for
responses distributed 50%: 50% with a confidence limit of 0.95). The research findings
were cross-checked with the data from the Department of Statistics of the Republic of
Lithuania (Statistics Lithuania) as of 1 January 2015. Distribution of the respondents
matched the population structure by age, gender and type of settlement. The survey was
an Omnibus survey using expectations questionnaire developed by the researchers to
find out what services and service providers would be chosen by respondents when
they need social care in old age. Also, information was collected about social-
demographic characteristics of the respondents, including age, education, place of
residence, income, marital status, children, if any, and their place of residence (in/
outside the country).

Between Formal and Informal Care, Public and Private Providers

What expectations about old age social services do adults aged 50–65 have as potential
users of such services in the near future? Considering that the eldercare system
encompasses both formal and informal service providers, respondents were asked
which of the service providers they would choose in old age. Table 1 below shows
that, in general, about 68% of all respondents prefer informal help providers (close
relatives, family members), about 22% of them would choose formal service providers
in old age, and every tenth respondent is not sure which service provider to choose in
the future.
Table 1 also reflects how respondents’ expectations differ/don’t differ depending on
respondents’ personal experience of caring for elderly family members and their views
 I. Blažienė, L. Žalimienė

Table 1 Expectations of respondents aged 50–65 regarding the type of care providers in old age (%)

To be chosen as service Groups of respondents by the type of expectations

providers in the future
Total N = Indicator: personal experience Indicator: views regarding
1205 of elderly care children’s responsibility to care
for their elderly parents

Ideal Predicted Normative Modern

expectations expectations expectations expectations
N = 392 N = 801 N = 697 N = 329

1 2 3 4 5 6
Informal care providers:
Family members, 67.8 65.6 79.3 81.1 50.1
relatives
Neighbours, other 1.9 1.7 1.0 1.0 2.8
informal carers
Formal care providers:
Public providers (state, 10.2 10.6 8.6 4.4 19.4
municipality)
NGO, charity providers 3.2 3.2 4.3 1.3 5.7
Private providers 8.5 9.2 3.4 4.6 15.1
Don’t know, no answer 9.1 9.7 3.4 7.6 6.9
Total 100.0 100.0 100.0 100.0 100.0

with regard to children’s responsibility to take care of their ageing parents. No

significant difference in expectations was found to exist between respondents with
personal experience of elderly care and respondents with no experience of elderly care
(p = 0.055, Cramer’s V = 0.109). It follows that ideal expectations and predicted ex-
pectations with regard to proffered elderly care providers coincide, i.e. personal
experiences of elderly care have no influence on the choice of the service provider type.
However, the survey findings show that the choice (expectation) of service provider
differs depending on socially endorsed norms of respondents. The question whether
children are responsible for taking care of their parents in old age was answered in such
a way: 58% of respondents believe that children must provide care for their old parents
no matter what; about one fifth of them (22%) think that children could be responsible
for taking care of their old parents only if such care is paid for, and only 13% of
respondents think that children are not responsible for taking care of their parents in old
age. Respondents supporting the view that children are responsible for taking care of
their parents in old age were defined as those with normative expectations and
respondents disagreeing with this socially endorsed norm and/or thinking that caring
for elderly parents by the children should be paid by the state were grouped as those
having modern expectations. The analysis of the distribution of differences between
those two cohorts in answering the question above (see columns 5 and 6 in Table 1)
indicated a significant difference between normative and modern expectations (p =
0.000 < 0.05, Cramer’s V = 0.367), but family care was nonetheless the most frequent
option in all types of expectations.
Between User’s Expectations and Provider’s Quality of Work: the...

The findings of this survey confirm previous findings that traditions of responsibility
of children to provide care for their ageing parents are still prevalent in Lithuania
(Stankūnienė and Maslauskaitė 2009). On the other hand, the survey suggests that
informal care by family members is not the absolutely dominant choice in old age.
There is a strengthening approach in Lithuania for recognition of the need for formal
providers of elderly care services or for higher levels of formalisation of family care.
Residents of regional centres and big cities are more often oriented towards private
service providers compared to rural inhabitants (10.6% and 5.0% respectively). Con-
sumption decisions are made in a specific location and depend on individual’s situation,
e.g. income. According to Statistics Lithuania (Income and Living conditions 2014),
income levels are considerably lower and poverty levels are higher in rural areas
compared to big cities, and this leads to a more frequent choice of public service
providers than private ones among rural population. A study conducted in Finland in
order to answer the question why older people choose private service providers
revealed a growing importance of private service providers among older people.
Reasons for choosing private services included better access to and quality of private
services, unavailability of such services in the public sector or lack of information on
public services (Puthenparambil and Kröger 2016). Currently, there are very few
private (business) service providers in Lithuania. Yet, figures in Table 1 suggest that
both public and private social care services appear to generate the highest demand in
the future compared to NGOs and church organisations as formal service providers.
Paying family members to care for their elderly loved ones is one of the instruments
to formalise activities of family caregivers. The findings of the survey indicate that
most adults aged 50–65 are ready themselves to assume carers’ responsibilities at the
end of their employment and to care for others both in a traditional, free-of-charge way
and for money. When answering the question BWhen you retire, would you like to help
other elder people who need help?^, more than half of respondents appeared to be
ready to help other elderly people for free or for money, and about one third of them
categorically opposed such activity in their future whether for free or for money (see
Table 2 below).
Such a disposition of elderly people to engage in care-giving activities can be
viewed as an important resource for service provision in the context of the growing
need for care services in the future and the ensuing increase in demand for workforce to
provide such services. It could be noticed that both in Europe and in other countries of
the world many informal caregivers are above 65. For instance, 65+ caregivers account

Table 2 Readiness of the elderly to help others upon retirement: for free and for money (%)

When you retire, would you like to help other elder people who need help? For free For money

Yes, I would 9.9 14.7

Yes, but only my family members or relatives 39.8 27.8
Yes, but only my neighbours whom I know 5.2 9.2
No, I wouldn’t 32.2 33.7
Don’t know, no answer 12.9 14.6
Total 100.0 100.0
 I. Blažienė, L. Žalimienė

for 30% in the United States, even for 42% in Australia (Dow and Meyer 2010) and for
39% in Finland (Johansson 2010). In Finland, retired informal caregivers are in
particular welcome and supported, because otherwise the state loses revenues and the
labour market loses employees who have to withdraw from the labour market while at
working age due to care responsibilities (Määttänen and Salminen 2017).

Between Family Care, Home Help and Residential Care Services

In order to elaborate expectations of people by the nature of preferred services (family

care, neighbour – volunteers’ care, home help, temporary housing, residential care
services), respondents were asked to rank their priorities for care. I.e. which type of
services would be chosen as the first priority, which one would be the second priority,
etc. The answers were distributed so that family care was the most frequently men-
tioned as the first priority (77%); the most frequent second priority was care from
neighbours, volunteers (37%) or home help services (25%); the most frequent third
priority was home help services (37%) or care from friends, neighbours, volunteers
(20.7%); temporal housing and houses of independent living was the most common
fourth priority (38.3% and 18.2%, respectively); the fifth most common priority was
sheltered housing (43.7%); residential care homes for the elderly appeared to be the
least prioritised alternative for as many as 70% of the respondents who ranked it as the
sixth priority.
Calculations of the mean score by each type of help/service (see Fig. 1 below)
clearly demonstrate respondents’ priority to choose family members as service pro-
viders in all types of expectations.
This means that family members as service providers received the highest
mean score (1.2–1.6) in all groups of expectations, whereas institutionalised
services, especially residential care, appeared to be the least desirable service in
all groups of expectations (scoring above 5 on the evaluation scale of 6-least
desirable).

Fig. 1 Ranking of service alternatives (mean score, where 1 is the strongest priority and 6 stands for the
weakest priority)
Between User’s Expectations and Provider’s Quality of Work: the...

Between Direct Service Provision and Cash for Care

One of the principles in organising social care services which has been particularly
emphasised in Europe in the last two decades is users’ choice between services or cash
for care (Glasby and Littlechild 2006; Yeandle and Ungerson 2006). The establishment of
cash for care/direct payments strategy reflects changes in the transition from traditional
paternalist services to greater service users’ power to take care of themselves (Hayes 2010).
This survey explored a likely demand for cash for care in the future from the
perspective of potential users. The survey findings demonstrate that about half of the
respondents (46%) would prefer cash to direct services. A statistically significant
correlation between holders of different types of expectations was not found (between
predicted expectations and ideal expectations p = 0.034 < 0.05; Cramer’s V = 0.086;
between normative and modern expectations p = 0.046 < 0.05; Cramer’s V = 0.086);
also, no significant difference was found to exist between women and men or rural and
urban residents in choosing between direct service provision and cash for care (Table 3).
It can be concluded in this context that cash for care is more often chosen by the
respondents preferring care from family members in old age (54%). Accordingly, there
exists a statistically significant, although weak, correlation between the choice of family
members as future eldercare-givers and the choice of cash for care (p = 0.000 < 0.05,
Cramer’s V = 0.256).
To sum up expectations of the elderly toward the infrastructure of eldercare services,
it appears that eldercare needs are primarily linked to care from family members and
other informal caregivers; home help services are given greater priority than residential
care; and most people are to give priority to the cash-for-care model.

Main Models of Providing Home Care Services

Considering the TSOL approach and multi-layered conceptual framework of labour

practices as well as users’ expectations and elderly care sector developments in other

Table 3 Respondents’ opinions about their preferred form of receiving elderly care services: cash for care or
direct service provision (%)

What type of service provision? Indicator: personal Indicator: views regarding

experience of elderly care children’s responsibility to
care for their elderly
parents

Predicted Ideal Traditional Modern

expectations expectations expectations expectations

To receive money to pay for services myself 56.9 44.4 45.9 49.4
To receive some part in cash and some part in direct 21.6 27.7 28.3 27.7
services
To receive all necessary services directly 12.9 20.9 19.2 20.1
Don’t know 8.6 7.0 6.6 2.8
Total 100.0 100.0 100.0 100.0
 I. Blažienė, L. Žalimienė

European countries (Pavolini and Ranci 2008; Simonazzi 2009; Rand et al. 2011; Kvist
2012; Farvaque 2013), we may single out three main organisational models of elderly
care at home which, at the same time, characterise different employment conditions and
patterns of job quality among service providers. Namely these models are likely to be
under the greatest demand in Lithuania in the near future, taking into account users
expectations regarding home care services, in particular:

Formal trilateral – service contract based – home care services provision model.
In this model, there are three main parties involved in service provision: organi-
sation providing services (employer), service provider (employee) and service user
(client).
Bilateral – employment contract based – home care services provision model. This
model involves two main parties participating in service delivery: service provider
(employee) and service user (employer).
Informal – non-contract based – model of providing elderly care services at home.
This model also has to two main parties participating in service delivery: service
provider (family member,) and service user (family member).

We may state that the formal trilateral model of providing eldercare services at
home mainly covers traditional market-oriented monetised labour practices (e. g.
formal paid labour in the private sector, formal paid labour in the public/third sector).
In rare cases, the formal trilateral model may cover non-monetised labour practices (e.g.
formal unpaid labour in the private, public or third sector) as well. The bilateral model
of providing eldercare services at home is mainly based on monetised labour practices,
but it might be implemented through both market-oriented and non-market-oriented
practices (e. g. formal paid labour in the private sector, paid informal labour, monetised
family labour). The informal model of providing eldercare services at home, on the
contrary, is mainly based on non-market-oriented labour practices, and might be
implemented through both monetised and non-monetised practices (e. g. paid favours,
monetised family labour, one-to-one non-monetised labour, non-exchanged labour)
(Fig. 2).
The interrelation among the trilateral/bilateral/informal models of providing
eldercare services and market/non-market and monetised/non-monetised labour prac-
tices is presented in the chart below.
Building upon the experience of Lithuania and other European countries, the main
service providers in the above models for providing home care services can be grouped
as follows (see Fig. 3 below):
In Fig. 3, the most prevalent providers of care services at home in Lithuania are:
public entities (trilateral model) and working and non-working informal caregivers
(informal model). The least developed in Lithuania are: the bilateral relations model
and private companies and NGOs (trilateral model) – namely these models and
providers (alongside with the system of support for informal caregivers) need to be
further developed and promoted.
The absolute majority of public entities (trilateral model) are represented by mu-
nicipal (local) social support centres which are responsible for organising home help
services for the elderly. The centres are budgetary institutions funded from municipality
budgets and small fees paid by service users.
Between User’s Expectations and Provider’s Quality of Work: the...

Monetised

Bilateral – employment

service contract based

non-contract based
contract based – model

Formal trilateral –

Informal –
– model
– model
Market Non-market

Non-monetised

Source: created by the authors, based on Williams (2010), Farvaque (2013).

Fig. 2 Interrelation among home-based eldercare service provision models and labour practices

Unlike in other European countries, home help services for the elderly provided by
private companies and NGOs, as well as services provided under the employment
contract based – bilateral relations – model, appear to be completely undeveloped in
Lithuania (although the law provides for opportunities for private individuals to deliver
home help services under business certificates).
The Lithuania’s dominant model of elderly care at home is informal care provided
by working or non-working family members. Though there is no statistics for the
numbers of informal caregivers, the main problem thereof is related to the fact that in
the majority of cases informal caregivers receive little support from the state/
community.
Further development of the trilateral and bilateral service models with participation
of a larger number of service providers (including family members) is one of the
directions for increasing accessibility/quality of elderly care at home in Lithuania.
Another direction of the development of care at home for the elderly is fostering of
co-production of services by multiple service providers. And there could be several
arguments why multiple service providers are desirable. Older parents wouldn’t like to
be dependent only on their children. They are more satisfied with intergenerational
relationships if they have a possibility to divide care responsibilities between formal
and informal providers. In other words, Bneither full public nor full private care is

Service contract Employment Non-contract

based – trilateral contract based – based – informal
relations – model bilateral relations – relations – model
model

Service providers: Service providers: Service providers:

● public entities ● self-employed ● working informal
● private companies ● non-formal employees caregivers
● NGOs (UDW) ● non-working informal
caregivers

Source: created by the authors, based on Farvaque (2013).

Fig. 3 Main types/models of elderly care at home
 I. Blažienė, L. Žalimienė

desired by elderly people^ (Le Bihan et al. 2013). Moreover, models for providing
mixed services produce the complementarity effect, when strengths of each provider
could be used for the benefit of the user.
The system of care services at home currently functioning in Lithuania is mainly
oriented towards a full set of services provided by a single service provider. I.e. if a
service provider is a public or municipal entity, it provides a full set of services, while
delivery of mixed services by multiple providers is not developed. This makes the
existing system very rigid. The development of co-production of services from different
types of providers would ensure the optimum use of resources through more flexible
combinations of services provided by different service providers. For example, services
provided by informal caregivers could be better combined with services from public or
private elderly care service providers. This would improve the effectiveness of the use
of elderly care services delivered by public or private providers and create conditions
for family caregivers to participate in the labour market.
However, in the context of developing in-home elderly care services provided both
by single or multiple service provider(s), it should be borne in mind that the develop-
ment of the aforementioned employment models inevitably means creation of new
jobs, including supply of less secure, atypical and precarious jobs. Therefore, from the
perspective of service providers, development of various models of in-home elderly
care services requires an analysis of the problems that employees providing such
services may face in terms of employment and job quality issues. The section below
discusses the job quality problems that are characteristic to different models of em-
ployment in home care in general, including in Lithuania.

Job Quality of Providers of Elderly Care Services at Home

It should be noted that any model of providing home care services for the elderly
involves increased risks for employees providing such services, since work at client’s
home poses higher physical and psychological threats for the employee and creates
preconditions for lower job quality. According to researchers analysing job quality
issues (Martel and Dupuis 2006; Dahl et al. 2009 etc.), the main dimensions of job
quality are the pay level and the strength of the employee’s connection to the labour
market, i.e. the level of job security. The level of pay and job security is low in case of
both trilateral and bilateral models of elderly care at home. However, the latter
dimension – the level of job security – is especially weak in the case of the bilateral
model, i.e. employment contract based elderly care at home model. Service providers
working on individual (formal or informal) agreements with a client are typically not
guaranteed usual employment conditions (and social guarantees in case of undeclared
work), full-time job and/or opportunities for advancement.
According to the authors of the article, the findings of the questionnaire survey of
home care workers conducted in Lithuania in 20161 show that workers of this sector are
often employed on fixed-term employment contracts, their average wage is close to

1
The survey was conducted under the framework of the research BTransformation of elderly care sector:
demand for services and labour force and quality of work^, funded by a grant (No GER-012/2015) from the
Research Council of Lithuania. Survey sample n = 420 home help service workers.
Between User’s Expectations and Provider’s Quality of Work: the...

minimum, they frequently have to work overtime, are often exposed to tiring or painful
working positions, need to lift/transfer the persons they care for, often feel stress/
emotional tension, are exposed to disrespectful behaviour, threats and/or harassment
from clients and their family members. Attention should be paid that female workers
represent the absolute majority of the sector’s workforce, most of workers are in older
age and more than a third of them have higher education although the nature of work
does not require it.
Similar trends are also observed in other EU and OECD countries within the entire
sector of long-term care for the elderly. Despite differences in job quality within the
care sector, which varies in different countries depending on the prevailing care models
and the role of the government in provision and funding of services, sector-specific
characteristics nonetheless include longer working hours, temporary nature of work,
low social guarantees, low wages, poor opportunities for training and improvement,
low status of employees, and the majority of sector’s employees being older women
(Giraldi 2010); in many countries, immigrant workers account for a large number of
care workers (Fujisawa and Colombo 2009; Colombo et al. 2011).
A comparison of the differences in working conditions between the two most
prevalent models of employment in elderly care at home (i.e. trilateral, when services
to the user are provided by persons employed within an organisation, and bilateral
when the service provider is directly employed by the service user) suggests that
employment relationships prevailing in the trilateral model are more standardised,
employees have higher qualifications and are offered better working conditions in
general, as compared to direct employment within a household (Angermann and
Eichhorst 2012). In the bilateral – employment contract based – elderly care at home
model, lower job quality has to do not only with the above-mentioned unfavourable
working conditions, but also with job insecurity issues. In Lithuania, persons providing
services under this model have two employment alternatives: self-employment and
undeclared work. In Lithuania, self-employed persons have only one legal basis for
providing home care services for the elderly, in particular, by obtaining business
certificates for this type of activity. However, such practices are rarely applied and
persons usually provide undeclared home-based eldercare services. By comparison,
many European countries quite broadly apply various specific forms of employment of
eldercare providers, including universal service employment cheques in France
(Chèque emploi service universel), service vouchers in Belgium (Titres services),
mini-jobs scheme in Germany, personal budget scheme in the UK, voucher scheme
(Buoni Lavoro) in Italy, tax credits and long-term care service vouchers in Finland, etc.
(Timonen et al. 2006; Yeandle and Ungerson 2006).
According to surveys carried out in Europe (e.g. Self-employed 2009), self-
employment is usually connected with low incomes, low social security, discontinuous
work, low skills, diffusion of long and non-standard working hours, the high incidence
of industrial accidents and work-related health problems, insufficient collective
representation.
Informal care providers (family caregivers) face even greater threats: many of them
not only have extreme physical and psychological loads when caring for their elderly or
disabled family members, but working caregivers have to combine caregivers’ respon-
sibilities with participation in the labour market and appear at permanent risk of losing
their job and, at the same time, the source of income and social guarantees. In
 I. Blažienė, L. Žalimienė

Lithuania, non-working informal family carers are insured only for basic pension and
health insurance. The flexible forms of employment are underdeveloped for combining
employment and care-giving, whilst possibility to receive respite care services for
people taking care of their relatives was introduced in Lithuania only in 2007. Accord-
ing to the findings of the qualitative survey of informal caregivers2 carried out by the
authors of this article in Lithuania in 2016, people caring for their disabled and/or
elderly family members at home permanently face such problems as housing and
environment not adapted to meet special needs what makes it more difficult to provide
care; health problems related to regular physical fatigue, lifting/turning of the disabled/
elderly person they care for; emotional and psychological fatigue, stress, lack of rest
and leisure time; lack of medical knowledge, nursing-related information, etc. Respon-
dents who have to reconcile their work and care responsibilities identify the following
conditions they happen to face regularly:

Byou have to be ready to leave your work at any time and go home, adjust your
working hours all the time depending on care-giving needs^;

Bcare usually takes all family’s time free of work, including weekends and
holidays^;

Bpermanent fear of job loss and concerns about the size of future pension^.

To sum up, we can say that the entire chain of home care services for the elderly,
starting from services based on formal employment relationships and ending with
informal care for family members, poses a broad spectrum of problems related to lower
job and employment quality. These problems require a broader and deeper analysis on
the part of both researchers and policy makers in order to ensure adequate working
conditions for formal employees providing in-home eldercare services and for informal
caregivers, concurrently creating preconditions for the development of eldercare ser-
vices at home.

Conclusions

The article provides insights into the situation and future development of elderly care
from a dual perspective of users of future eldercare services at home and of service
providers. Empirical indicators employed for the analysis are expectations of Bfuture
users^ (adults currently aged 50–65) of eldercare services and organisational models of
providing eldercare services at home, as well as coherent changes in job quality.
Although expectations are a multidimensional phenomenon and are influenced by
past experiences, traditions, and personal and social factors, the analysis covered four
types of expectations of the future elderly. The findings obtained suggest that respon-
dents’ personal experiences in caring for elderly family members (defined as ideal and

2
The survey was conducted under the framework of the research BTransformation of elderly care sector:
demand for services and labour force and quality of work^, funded by a grant (No GER-012/2015) from the
Research Council of Lithuania.
Between User’s Expectations and Provider’s Quality of Work: the...

predicted expectations) have no effects on the choice of forms of care in the future.
However, significant differences were found between normative and modern expecta-
tions: respondents supporting the traditional view that adult children are responsible for
taking care of their parents in old age (normative expectations) more frequently
reported their preference for care from family members than those who disagreed with
it (modern expectations). The findings of the survey give grounds to conclude that,
along with informal family care which was most often expected by respondents in their
old age, there is another strengthening approach in Lithuania towards the need for
formal providers of eldercare services.
Expectations towards formal care services are centred primarily on home help
services. Calculations of the mean score by different types of elderly care services
demonstrate respondents’ priority to choose home help services in all types of expec-
tations, whereas institutionalised services, especially residential care, appear to be the
least desirable service in all groups of expectations. In addition, many respondents are
ready themselves to assume paid carer’s responsibilities at the end of their employment.
This is indicative of the need for higher levels of formalisation of family care (at home)
in the future and the need to put on the agenda the issue of job quality of such carers.
The findings of the survey also suggest that in the future there will be two groups of
providers of elderly care services among retired individuals who have ceased their
professional career: individuals ready to take responsibilities of informal carers and
those disposed to provide paid help to others. Members of the latter group can be
characterised as inclined to start their second career as caregivers. The aforementioned
survey does not provide information as to the forms and methods those people think
they could use in providing waged care services (e.g., provide private services indi-
vidually, get employed with private or public institutions, etc.). Such information would
be important for further research, for instance in forecasting labour supply in the
eldercare sector.
This survey explored a likely demand for cash-for-care strategy in the future from
the perspective of potential users in all groups of expectations. Respondents with
personal experience of elderly care chose cash for care more frequently, which is
indicative of their dissatisfaction with direct services. Those who disagreed with the
socially endorsed norm that adult children should definitely take care of their elderly
parents (modern expectations) also more frequently opted for cash for care than those
who supported the aforementioned norm. Supporting the opinion that the tradition of
familial care is decreasing in our society in general, this circumstance is also assumed to
reinforce the need for cash for care. Accordingly, adults currently aged 50–65 will be
particularly interested in cash-for-care schemes. This, again, turns our attention to
organisational models of service provision which are necessary to put the cash-for-
care into practice.
To sum up expectations of 50–65 year-old adults toward the infrastructure of
eldercare services, it appears that eldercare needs are primarily linked to care from
family members, home help services, and cash-for-care schemes. All this gives room
for highlighting the growing variety of models of providing home care services and
forms of employment in the eldercare sector, and the need to assess how these forms
can influence the quality of jobs in the sector.
Using the total social organisation of labour approach as a point of departure, the
article distinguishes between three main organisational models of elderly care at home
 I. Blažienė, L. Žalimienė

which, at the same time, characterise different employment conditions and patterns of
job quality among service providers. We presume that namely these – formal trilateral
(service contract based), bilateral (employment contract based) and informal (non-
contract based) – home care service provision models are likely to be in the greatest
demand in Lithuania in the near future, taking into account users’ expectations regard-
ing home care services.
Given that these models encompass both market/non-market and monetised/non-
monetised labour practices and are highly related to the development of non-standard
forms of employment, particular attention should be paid to the issue of improving job
quality for sector’s employees. Other areas important in terms of balancing the needs of
elderly people for care at home and job quality of various service providers in Lithuania
include the development of new employment forms in providing home care services
and of system of support for informal caregivers.
Different types of expectations of the future elderly (now aged 50–65) suggest that
the existing underdeveloped organisational models of elderly care at home will not
meet their expectations in the future. Consequently, there should occur new, more
flexible forms of employment to meet those expectations, what means lowering of the
quality of jobs for sector’s employees.
The analysis of interrelation among home-based eldercare service provision models
and the Williams’ (2010) multi-layered conceptual framework of labour practices
provide new insights into the spectre of labour practices with a focus on non-contract,
services contract, and employment-contract-based employment models. This allows the
extension of the framework of labour practices analysis and a more fundamental study
of employment peculiarities. We hope this paper will encourage future research in order
to embed this particular employment aspect (parties involved in service provision)
within the conceptual framework of labour practices.

Funding This research was funded by a grant (No GER-012/2015) from the Research Council of
Lithuania.

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