Social care in Europe

“The provision of social care in europe is diverse and comparisons indicate that there is more difference than similarity despite the growing arguments for convergence.” Evaluate the statement with reference to at last one broad area of welfare provision, at least 2 EU members states and the convergence debates such as globalisation, EU policies or shared internal factors.

Introduction

Those who study the social world, in particular Giddens (1991) maintain that social structures are both constraining and enabling and thus they advantage some people and disadvantage others. In the aftermath of World War Two western states attempted to forge closer links with each other and this formed the basis of what has come to be known (especially since the 1980s) as globalisation. This coupled with increasing industrialisation has resulted in financial and social changes in many countries. It is here that we have the beginnings of convergence, not all countries however have been affected with the same intensity.^[1]Industrialisation has spread across the world and most industrialised countries are what is known as welfare states. In a welfare state the government acts to reduce inequalities and make provision for certain services within the community. It is especially aimed at those who struggle within a market economy to provide for their own basic needs (Giddens, 2001). Spending and types of welfare provision differ but in many cases will include housing, pensions, education and health. Giddens (2001) argues that as society changes, due to the effects of industrialisation and globalisation so must the nature of the welfare state. The increasing stresses of modern life, advances in technology and patterns of work have affected all areas of people’s lives and in many instances this has had repercussions in people’s health.

Weare (2001), in a review of the work of Lavikainen et al (2000), says they maintain that mental health care has been the Cinderella of health provision in Europe and now needs to be at the front of the agenda on health. The authors maintain that mental health is now coming to be understood as an integral part of public health and thus is worthy of greater promotional efforts. The idea is to promote positive views of mental health within the community. There are similarities here with the way in which mental health issues are being approached in Britain. Walsh et al (2000) have argued that there has been a growing tendency for governments to take a positive view of both physical and mental health and relate it to lifestyle. In this way governments place the responsibility for health firmly on the shoulders of those who suffer from ill health, whether this be physical or mental.

This paper will examine mental health provision in Finland and Germany. It will look at areas of similarity and difference in the context of convergence debates which indicate that there may be more similarity than difference in the provision of mental health care.

Within the European Union sources estimate that mental health provision accounts for between three and four percent of the gross national product. In her review of Gaillie’s (2000) book Maani (2001) says that the authors demonstrate that welfare provision across Europe has been increasingly affected by the growth in unemployment in many countries during the nineteen nineties. Unemployment and the stresses that are placed on those who remain in employment significantly affect the health of those involved and thus have a corresponding effect in the cost of welfare provision. The number of people with mental health problems is on the increase and this is becoming increasingly evident in the workplace.

A study conducted by the International Labour Organisation into the incidences of mental health problems in the workplace found that in Finland and Germany as many as one in ten workers was found to be suffering from depression, stress or anxiety and that this could often result in hospitalisation and sometimes loss of employment (ILO, 2001). In Finland, the report estimates that somewhere in the region of fifty percent of the workforce suffer from mental health problems and mental health disability payments are on the increase (ILO, 2001). In their study of factors affecting mental health in Finland Viinamaki et al (1995) found the major causes to be unemployment, financial problems, and insufficient social support. Women were more likely than men to suffer from mental health problems.^[2] The provision of psychiatric services has become extremely diffuse and in-patient services for mental health have been totally disbanded in Finland.^[3] At the same time a Finnish website on a number of health related matters claims that:

The state of people's health and welfare in Finland has steadily improved since healthcare and health promotion were established. The main challenges nowadays relate to disease prevention, mental health problems and the disparities in health, welfare among different population groups. Finnish health policy has become matched to international standards set by the World health organisation and the European Union (Suomen Ash, 2005).^[4]

Spending on health in Finland is, however, lower than many developed countries as its spends a lower percentage of its gross national product on health. Germany on the other hand is one of the highest spenders on health (WHO) The Finnish Government website nevertheless states that health provision in Finland is among the best in Europe yet at the same time it maintains that spending must be increased if inequalities in health are to be addressed and to ensure that people have equal access.^[5] Mental health difficulties and the provision of mental health services appear to be a growing global problem. In Germany the cost of absenteeism due to mental health problems is rapidly increasing and seven percent of early retirements account for those who suffer with depression and other mental health related illnesses. In a study undertaken in Germany Klose and Jacobi (2004) that being unmarried and becoming unemployed were significant factors in mental health problems and that this affected more men than women. This differs from the findings in Finland where more women than men are affected by these factors. In Germany there is no distinction between mental health and physical health as both are treated in the same way. There is widespread inter-agency co-operation in Germany to cope with the rehabilitation of those suffering from ill health. Mental health is an economic burden in Germany as work related stress and burnouts are on the increase.^[6]

McBeagle (2000) maintain that health practitioners and health services in many countries face a growing challenge from the impact of globalisation. The free movement of both capital and people has brought social and economic changes to most developed countries, not all of these changes have been beneficial. There is no clear agreement as to how these processes affect health provision and policy making but Woodward et al (2001) maintain that there is:

however, an increasing tension between the new rules, actors and markets that characterise the modern phase of globalisation and the ability of countries to protect and promote health (Woodward et al, 2001)..

It is clear then that mental health provision is becoming a matter of global concern and also that there is a rapidly growing adoption of mental health promotion projects across Europe. A report from the World Health Organisation documents the following:

Currently, more than 40 per cent of countries have no mental health policy and over 30 per cent have no mental health programme, and around 25 per cent have no mental health legislation. WHO also says that’the magnitude of mental health burden is not matched by the size and effectiveness of the response it demands. Over 33 per cent of countries allocate less than 1 per cent of their total health budgets to mental health, with another 33 per cent spending just 1 per cent of their budgets on mental health. About 25 per cent of countries do not have the three most commonly prescribed drugs used to treat schizophrenia, depression and epilepsy at the primary health care level. There is only one psychiatrist per 100,000 people in over half the countries in the world, and 40 per cent of countries have less than one hospital bed reserved for mental disorders per 10 000 people.^[7] (WHO 2002)

Research has found that early education concerning mental health is vital if a growing international problem is to be addressed. Weare (2004) argues that it is not easy to promote such issues in schools because educational providers do not always see a link between education in schools and mental health issues. This situation is rapidly changing however, and following projects in the US and UK Germany has adopted the promotion of mental health in its schools and this is now being taken up by other European countries (Weare, 2004). Solin and Lehto (2004) say that while health promotion is becoming a highly debated topic in most European countries, including Finland but that it is highly problematic in terms of policy making. Because mental health itself is difficult to define this also causes problems in terms of promoting positive mental health. While there are convergences in health promotion, in how services are provided and the economic effects of mental health Woodward et al (2001) maintain that:

The relationship between the three processes of globalisation is circular: increasing flows stimulate the development of global rules and institutions, which promote the opening of economies, which increases the scale and scope of cross-border flows. The globalisation process is influenced by a number of driving and constraining forces: technological developments, political influences, economic pressures, changing ideas, and increasing social and environmental concerns (Woodward et al, 2001:4)

The World Trade agreement, for example has had an effect on the price of pharmaceuticals and the WHO maintain that this affects treatment across the globe, furthermore, it is arguably the case that this is particularly relevant to mental health where many health providers still rely heavily on drug treatment such as anti-depressants and drugs such as Lithium which is given to those with bi-polar disorders. In Germany 60% of those diagnosed with mental health problems suffer from depression and 75% of this number are treated with psychopharmaceutical drugs when their depression may be due more to social factors than mental/psychological ones (ILO, 2001). Bilton et al (1996) contend that the discourse of modernity envisaged growing economic and social similarity around the world and a growth in the notions of equality and justice. The truth, they argue, is rather different. At the national level there may seem to be a coming together (at least in the west) but in local terms it has tended to produce chronic disadvantage and inequalities. In this sense globalisation can be said to exclude people as much as it includes, certainly the continuing existence of unequal structures pertain at a global level. These inequalities have been exacerbated by the growth of the Trans-National Corporations and by changing patterns of employment across Europe..

There is a growing opposition to the forces of globalisation as many people argue that these forces have a tendency to exclude as much as they include, and this has brought about greater imbalances in society.. People are also unhappy with the way in which the trans-national corporations operate, often having more say in how a country is run than the democratically elected government.^[8] Sklair (1995 ) argues that the power of the nation states to effect significant change through policy making is apparently doomed to failure in an increasingly global world. This is extremely important when it comes to welfare provision. With costs escalating many countries are downsizing their welfare programmes, Giddens (1994) maintains that:

The new period of globalisation attacks not only the economic basis of the welfare state but the commitment of its citizenry to the equation of wealth with national wealth. The state is less able to provide effective central control of economic life (Giddens, 1994:140).

In a number of countries in Europe the cost of mental health is increasing but difficult to pin down. This is because mental health problems often pre-date other conditions such as heart problems and high blood pressure. While welfare provision generally is quite good in Finland services are paid for out of the public purse which comes from taxation but in the area of mental health there is a gap between needs and service provision. Much of this provision is administered at local level and so there are disparities between one area of the country and another.^[9]

Problems, such as lack of resources for community care, insufficient recognition of the needs of the severely mentally ill, and difficulties in guaranteeing continuity of services, have arisen as a result of the move from specialised psychiatric services to primary care (ILO, 2001:9).^[10]

Primary health care is free for everyone in Finland but if a person needs to be hospitalised then (since 1996) this has to be paid for on a daily basis and long term care is charged on a means tested basis.^[11] The shift to primary care in mental health services is happening in Germany as well as Finland and it is this kind of shift that raises the question of whether the forces of globalisation tend to push countries into adopting similar kinds of policy making. Harlan (2001) has this to say:

One of the most intense debates in International Political Economy over the

past decade has revolved around the question of whether these trends in globalisation have forced nations to follow the same economic policies. Those who argue for convergence, whether they approve of it3 or not,4 maintain that powerful economic forces, combined with the ideological hegemony of Anglo-Saxon economic ideas, have forced states to adopt neo-liberal policies. Others, however, argue that a convergence towards neo-liberal economic ideas is not preordained, since other economic models can adapt to globalisation and even have advantages over neoliberalis (Harlan, 2001:3)..

Some theorists argue that convergence leads to privatisation and marketisation and could result in an American model of virtually no welfare provision. Harlan (2001) maintains that this is a frightening thought for many Europeans and they would therefore look for policies that tended to shift away from convergence. Garrett (1998) argues that those European welfare states whose policies lean towards the left will have more success in dealing with the forces of globalisation than those who lean to the right. In Germany problems with the economy and some aspects of welfare provision has meant that German policy making changes rapidly and thus it veers away from convergence. However, Europeanisation has had far reaching effects and placed a number of constraints on how the German Government handles its economy and its policy making, it is thus affected by forces other than those attributed to globalisation (Harlan, 2001).

Conclusion

There are significant similarities between Finland and Germany when it comes to mental health issues. In Germany however there is not the same charge for in patients as there is in Finland. Finland appears to be following the convergence model. Yet in its adoption of payment for secondary health services it is moving closer towards an American model of health than a European one. Germany on the other hand appears to have many similarities with other European countries but as Harlan (2001) suggests rapid economic and policy changes mean that it often veers away from convergence while at the same time feeling itself constrained through membership of the European union.

Clearly there are many areas of convergence in mental health problems and provision in Finland and Germany. However, there are also a number of divergences that lead to the supposition that there is not a clear cut argument in either case. Nevertheless it might be argued that because the TNCs have considerable influence over economic policies in many countries it might be the case that convergences in this area could have effects in other areas thus contributing to the view that there is a movement towards convergence in welfare provision in European countries.

2,500 words

Bibliography

ILO report: 2001 “Mental health in the workplace in Finland, Germany, Poland, the UK and the USA” Journal of European Industrial Training; Volume 25 No. 2; 2001

.

Garrett, G. 1998. Partisan Politics in the Global Economy Cambridge, New York: Cambridge University Press

Harlan, C. 2001 Europe and the third way: Gerhard Schröder and Globalisation

Paper for the 51st Political Studies Association Conference

10-12 April 2001, Manchester, United Kingdom

Bilton et al 1996 3^rd ed. Introductory Sociology London, Macmillan

Giddens, A. 2001. 4^th ed. Sociology. Cambridge, Polity Press

Giddens, A. 1994. Beyond Left and Right: The Future of Radical Politics. Cambridge, Polity Press.

Giddens, A. 1991. Modernity and Self-Identity: Self and Society in the Modern Age Cambridge, Polity Press.

Sklair, L. 1995. Sociology of the Global System. Hemel Hempstead, Prentice Hall/Harvester Wheatsheaf

http://www.vwl.uni-mannheim.de/fiwi/download/pfpg_06_17.pdf

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=7484200

http://www.stakes.fi/english/publications_2000-2004/engl2005/M202.htm

http://www.suomenash.fi/sivu.php?artikkeli_id=178

http://www.stm.fi/Resource.phx/eng/subjt/inter/who/index.htx Ministry of Social Affairs and Health

http://www.ilo.org/public/english/employment/skills/disability/papers/execsummaries17.htm

http://juno.emeraldinsight.com/vl=1167930/cl=45/nw=1/fm=html/rpsv/cw/mcb/09526862/v15n1/s3003/p3l

http://news.bbc.co.uk/1/hi/special_report/1999/02/99/e-cyclopedia/711906.stmre

http://www.euro.who.int/eprise/main/who/progs/chhfin/home

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^[1] http://www.vwl.uni-mannheim.de/fiwi/download/pfpg_06_17.pdf

^[2] http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=7484200

^[3] http://www.stakes.fi/english/publications_2000-2004/engl2005/M202.htm

^[4] http://www.suomenash.fi/sivu.php?artikkeli_id=178

^[5] http://www.stm.fi/Resource.phx/eng/subjt/inter/who/index.htx Ministry of Social Affairs and Health

^[6] http://www.ilo.org/public/english/employment/skills/disability/papers/execsummaries17.htm

^[7] http://juno.emeraldinsight.com/vl=1167930/cl=45/nw=1/fm=html/rpsv/cw/mcb/09526862/v15n1/s3003/p3l

^[8] http://news.bbc.co.uk/1/hi/special_report/1999/02/99/e-cyclopedia/711906.stmre

^[9] http://www.ilo.org/public/english/employment/skills/disability/papers/finpart3/finpart39.htm

^[10] http://www.ilo.org/public/english/employment/skills/disability/papers/finpart3/finpart39.htm

^[11] http://www.euro.who.int/eprise/main/who/progs/chhfin/home