Charlotte Bredal, Kasper Manniche, and Amalie Dam-Hansen On the Corona Frontline The Experiences of Care Workers in Denmark

FRIEDRICH-EBERT-STIFTUNG – POLITICS FOR EUROPE Europe needs social democracy! Why do we really want Europe? Can we demonstrate to European citizens the opportunities offered by social politics and a strong social democracy in Europe? This is the aim of the new Friedrich-Ebert-Stiftung project»Politics for Europe«. It shows that European integration can be done in a democratic, economic and socially balanced way and with a reliable foreign policy. The following issues will be particularly important: – Democratic Europe – Social and ecological transformation – Economic and social policy in Europe – Foreign and security policy in Europe We focus on these issues in our events and publications. We provide impetus and offer advice to decision-makers from politics and trade unions. Our aim is to drive the debate on the future of Europe forward and to develop specific proposals to shape central policy areas. With this publication series we want to engage you in the debate on the»Politics for ­Europe«! About this publication This paper looks at the impact of the COVID-19 pandemic on elder care in Denmark and examines the response of the Danish trade union FOA. Danish elder care faces a wide range of problems, including time pressure and staff shortages. Yet the death toll among older people in Denmark has been low compared to many other countries. Nonetheless, by March 2021 we had sadly seen 923 deaths in care homes. The main issues for the trade unions have been providing immediate support to members, union branches, and shop stewards and helping them to understand changing guidelines. Negotiating with employers and government and helping to secure adequate workplace PPE have also been important. About the Authors Charlotte Bredal, senior consultant, working environment Kasper Manniche, chief economist Amalie Dam-Hansen, consultant, health policy Partner organizations Arena Idé is a Stockholm-based independent progressive think tank, funded by the Swedish trade union movement. www.arenaide.se Kommunal is Sweden’s largest public sector union with more than 500,000 members. www.kommunal.se FOA is a trade union with 175,000 members and 38 branches around the country. Its members include social and health care workers, social and health care assistants, day care workers, cleaning staff, kindergarten assistants and nursery school assistants. FOA is the largest trade union in the Danish elder care sector. Responsible for this publication within the FES Dr Philipp Fink, Director, FES Nordic Countries Josefin Fürst, Policy Officer, FES Nordic Countries

Introduction 1 INTRODUCTION This paper looks at the impact of the COVID-19 pandemic on elder care 1 in Denmark and how the Danish trade union FOA has responded. Danish elder care faces a wide range of problems, including time pressure and staff shortages. By 2030, the number of people over 80 years will increase by 160,000 and already today municipalities face serious problems recruiting new employees(Danmarks Statistik 2021). On March 11, 2020, the Danish government imposed a lockdown and cancelled all“unnecessary activities and services.” This naturally also affected elder care. Activity centers for older people were temporarily closed and the municipalities reduced the level of help offered in private households, for example cancelling cleaning services. The government also introduced restrictions on visits to care homes. These mea­ sures were necessary to reduce transmission, but for some older people led to problems of loneliness and decreased mobility. A comparison of mortality among older people in Denmark and other countries reveals, however, that the government’s strategy saved many lives. Nevertheless, by March 2021 there had been 923 deaths in Danish care homes. In total, 45 billion DKR is spent on elder care in Denmark per year(see SCB 2020). That represents about 8 percent of total public spending on welfare. Care homes account for approximately half of spending on elder care, and domiciliary care approximately 30 percent(the remaining 20 percent is spent on preventive measures, assistive devices, etc.). 36 percent of those who receive domiciliary care choose private providers(see SCB 2020). We face a wide range of problems in Danish elder care; employees are pushed for time, and there is a shortage of staff. By 2030, the number of people over 80 years will increase by 160.000 and the municipalities already face serious problems recruiting new employees. We also have a shortage of skilled employees. In fact, the problem has never been bigger. In 2015, the share of unskilled employees was 14 percent, in 2020 it is 21 percent. This is a really negative development that has consequences for the quality of elder care. 2 COOPERATING TO IMPROVE ELDER CARE During the summer of 2020, a media investigation uncovered severe neglect in a care home, recorded by relatives using hidden cameras. During the early phase of the COVID-19 pandemic there was a shortage of personal protective equipment(PPE) in Denmark, and the Danish Health authority(Sundhedsstyrelsen) decided to give highest priority to the hospitals. Consequently, there was a shortage of PPE in the elder care sector which compromised the working environment and increased fear of infection and transmission of infection. The main issues for the trade union FOA have been providing immediate support to members, local union branches, and shop stewards and helping them understand the guidelines, as well as negotiating with employers and the government and helping to secure adequate PPE. We also had to ensure that employers followed the guidelines for employees belonging to“risk groups”(cardiac conditions, asthma, etc.) and that they received sick pay and so on(FOA 2020a). THE STRUCTURE OF THE ELDER CARE SECTOR Danish elder care is primarily organized, run and financed by the public sector. The Danish municipalities are responsible for the provision of elder care. If you need help, your needs will be assessed by the municipality. The help provided will either be domiciliary care services(help in your own home) or a care home. If you receive domiciliary care, you can choose between a public or a private provider. Either way, however, the public sector still pays for the service. As a consequence, FOA, the Danish Minister of Health and Elder Care Magnus Heunicke, Local Government Denmark (KL, the organization of the 98 Danish municipalities), and Ældresagen(the organization for older people) hosted a two-day summit on how elder care can be made more sustainable. The idea was to identify the most important challenges to elder care. For example: quality of work in the sector, recruiting and skill development, professional management, quality and regulatory oversight, visiting arrangements, and organization of elder care. After the summit a public consultation ran until the end of 2020(Sundhedsministeriet 2020). The four summit partners are now turning the many ideas and suggestions into concrete proposals. Another summit will be held in the second half of 2021. WORKING CONDITIONS IN ELDER CARE PERSONAL PROTECTIVE EQUIPMENT(PPE) During the early phase of the COVID-19 pandemic there was a shortage of personal protective equipment(PPE) in Denmark, and the Danish Health authority decided to give highest priority to the hospitals. Consequently, there was a shortage of PPE in the elder care sector, which compro1 This report uses the terms“elder care”,“care” and the“care sector”, referring to what in the UK is called adult social care for older people. 2 These figures are estimates by the authors and currently not published. For access to the data, please contact the authors.

FRIEDRICH-EBERT-STIFTUNG – POLITICS FOR EUROPE 2 mised the working environment and increased fear of infection and transmission. “When the prime minister closed the country in March, my workplace(like all the others in the municipality) was asked to hand in most of our PPE to a shared remote storage facility. Therefore there is a shortage of PPE in many care homes.” Social and healthcare assistant(FOA 2020) It has been hard to get access to PPE, but I know my manager struggles to get it. The guidelines have been changed several times. My line manager has been accessible and clear throughout, though.” Social and healthcare assistant(FOA 2020) Our members felt that their line managers were generally clear in their communication about the guidelines. There was, however, confusion about the guidelines for PPE when working close to older people with no symptoms of COVID-19. The fear of infection and transmission of infection was lower among employees who felt secure about the organization and planning of their work. During the first wave the guidelines to elder care staff about PPE, hygiene, testing and so on, were constantly changing, and it was very difficult for FOA to help and guide our members because we were not informed and updated on a regular basis. At the same time, we were extremely busy(to put it mildly) helping and guiding members in difficult situations without adding to the feeling of panic. The employers were equally busy. As a result, the only support the workplaces received was an FAQ website and a hotline run by the Danish Health authority. The Danish Working Environment Authority(Arbejdstilsynet: WEA), the state agency responsible for ensuring that employees have a safe and healthy working environment, was sent home and did not really come back to work until August 2020. COVID-19 RISK MANAGEMENT IN THE WORKPLACE, FEAR OF INFECTION AND FEAR OF TRANSMISSION OF INFECTION AMONG FRONTLINE EMPLOYEES We knew that fear of infection and fear of transmitting infection between work and family affect healthcare workers’ willingness to work during epidemics. Yet, we found there was a lack of knowledge about COVID-19 risk management, fear of infection and fear of transmission among frontline employees, particularly outside the hospital sector. To change this, FOA carried out a survey among its members in spring 2020 on COVID-19 risk management in the workplace, fear of infection and fear of transmission of infection among frontline employees(FOA 2020b). 10,519 individuals from our voluntary member panel were invited to respond to an electronic questionnaire. Responses were treated confidentially. In an article prepared in collaboration with the University of Copenhagen, we compared COVID-19 risk management, fear of infection and fear of transmission of infection among frontline employees working within five areas of work: elder care, hospital/rehabilitation, psychiatry, childcare, and ambulance services. We investigated whether group differences in fear of infection and transmission could be explained by differences in risk management. We also investigated the association of risk management with fear of infection and fear of transmission of infection among elder care personnel. We found that of the five areas of work, fear of transmitting infection during work was most frequent in elder care (55 percent). Not all differences in fear of infection and transmission between the five areas of work were explained by differences in risk management. Among elder care personnel, self-reported exposure to infection and lack of access to tests were most consistently associated with fear of infection and fear of transmission, whereas lack of access to personal protective equipment was solely associated with fear of transmission(Nabe-Nielsen et al. 2020). “It is a great worry for me, that I don’t know if I might infect some of the residents of the care home. I don’t visit my own old parents, because I am worried that I might infect them. I work in elder care and I don’t have any kind of PPE or protection. It is really hard for me.” Employee in a care home(FOA survey 2020) This knowledge is important, as fear and stress can result in poor mental health and as these emotional responses are associated with willingness to work during a pandemic. Also, indicators related to knowledge, communication and trust in the workplace’s risk management were associated with fear of infection and fear of transmission. Our results show clearly that COVID-19 risk management outside the hospital sector should be addressed and prioritized as part of the public strategy for handling this and future pandemics. We hope the results of our collaboration with the university of Copenhagen can foster a dialogue between labor and employers’ organisations in Denmark about the challenges in the elder care sector that need to be addressed in order to improve the response to the current and future pandemics(Nabe-Nielsen et al. 2020). Our findings illustrate the need to pay attention not only to health professionals in hospital settings but also to other groups of frontline employees, as the latter group may encounter similar challenges in terms of the need for protecting themselves, their family and their clients from infection. The involvement of a union in the research process enhances the possibilities for communicating findings directly to practitioners. For the union, the involvement of the researchers ensures that the results are taken more seriously. Additionally, it has been a way to strengthen the focus on occupational health and safety(OHS) in relation to COVID-19.

Elder care and the coronavirus 3 “THE RIGHT SKILLS FOR THE RIGHT TASKS” FOA has also cooperated with The Danish Center for Social Science Research(Det Nationale forsknings- og analysecenter for velfærd: VIVE) around the project“The Right skills for the right tasks”. The aim of this project is to find out what we have learned from Covid-19 in the health and elder care sector. The final report comes out in May 2021. We hope this cooperation can help us to be clearer on some of the positive lessons. For instance, some of our members have experienced greater self-management and better collaboration between colleagues. The key task has been clearer and FOA members have experienced greater acknowledgement of their skills and contribution. “We have changed the way we work, and it has actually made our working day better, so it has really opened our eyes to ways we can continue to work differently when this epidemic is over. So maybe some good will come out of this unfortunate situation – maybe we can become more liberated from always working in the same way.” Social and healthcare assistant(FOA 2020). UNIONIZATION, EDUCATION AND PAY FOA is the largest trade union in Denmark organizing employees in the elder care sector. The rate of unionization among the social and health workers(all potential FOA members) in the municipalities is 71 percent. Among the skilled workers(social and health helpers and social and health assistants, FOA members), the rate of unionization in the municipalities is 79 and 85 per cent, respectively (FOA 2019, based on membership numbers and data from Kommunernes- og Regionernes Løndatakontor. FOA mainly organizes two groups of employees working within elder care: social and health care helpers, and social and healthcare assistants. These groups have vocational education and training for adults(VET). The level of education is two years and two months for social and healthcare helpers, and three years and ten months for social and healthcare assistants. Their gross monthly pay is approximately 31,000 DKR(approx.€4,161). These measures were necessary to reduce transmission, but for some older people led to problems of loneliness and decreased mobility. A comparison of mortality among older people in Denmark and other countries reveals, however, that the government’s strategy saved many lives. It took a while before the government published guidelines about how to best mitigate the impacts on older people. The first government guidelines were published on March 12, but were unclear regarding when and in what situations PPE should be used. It would have been very helpful for care workers and would have avoided a lot of pain and suffering among older people and their relatives if these guidelines had been clearer and available at an earlier stage of the pandemic. All the same, the FOA members did a great job of making the best of the situation and reducing suffering. Here is an example from a survey conducted by FOA in 2020, describing how care workers tried to compensate the hardships during the restrictions: “I experience rising interest in giving more good experiences to residents. It could be small walks, singing, gymnastics. It’s almost like a competition. How can we do that little extra? It makes the colleagues happier too, when they feel that they make a difference in a hard time.” Social and health care worker(FOA 2020) MORTALITY IN ELDER CARE By March 2021, there had been 2,395 deaths caused by Covid-19 in Denmark. In Denmark’s 98 municipalities there are about 930 care homes for older people with more than 40,000 residents(Statens Serum Institut 2021). However, older people living in their own home associated with a care home are not included. We had 923 deaths and 3,681 confirmed COVID-19 cases in care homes by March 2021. There have been cases of COVID-19 at 398 care homes. 35,093 tests have been conducted among residents(Statens Serum Institut 2021). TRADE UNION PERSPECTIVES ELDER CARE AND THE CORONAVIRUS LOCKDOWN, SERVICES AND VISITS IN ELDER CARE On March 11 2020, the government imposed a lockdown, cancelling all“unnecessary activities and services.” This naturally affected elder care. Activity centers for older people were temporarily closed in March 2020 and the municipalities reduced the level of help offered in private households, for example cancelling cleaning services. The government also introduced restrictions on visits to care homes. In some cities these were still in place in November 2020. For FOA, the main issues during the pandemic have been to secure adequate accessibility to PPE in workplaces, and to understand, communicate and influence the guidelines so they are clear and suited to protect both the older people and the employees. We also had to ensure that employers followed the guidelines regarding the union members who belong to“risk groups”(cardiac conditions, asthma, etc.) so that they could stay home from work and receive their sick pay. One of our main challenges has been, and still is, the pace of change in the infection and hygiene guidelines. For instance, the guidelines about how to deal with COVID-19 in the health care sector have been revised 21 times and the

FRIEDRICH-EBERT-STIFTUNG – POLITICS FOR EUROPE 4 guidelines about PPE four times(Sundhedsstyrelsen 2021; Sundheds- og Ældreministeriet 2020b). Our victories have been achieved through hard work influencing the government and the employers’ side through negotiations, and collective pressure from FOA and fellow trade unions – and other interested organizations. We have helped to ensure: – Sharper and clearer guidelines about when and how to use PPE. – A government plan for assisting employees who are in a risk group and/or have been infected. – That Covid-19 is treated as an occupational injury in the health care sector. – A government board to secure PPE and test capacity. – A tripartite agreement about elder care(Sundheds- og Ældreministeriet 2020a). – More resources for hygiene and cleaning. – That students were exempt from normal more costly union dues if they volunteered to participate in emergency response activities. Normally in Denmark you do not have to pay full union dues if you are a student. Students who took part in the emergency response were asked to pay a higher pension payments and full union dues. Danish trade unions made an agreement with the Ministry of Labor to end this policy. – That the Working Environment Authority resumed visiting and inspecting health and safety conditions in workplaces in August 2020. There should, of course, be proper access to tests and PPE, and it is important that the authorities and local leaders ensure that employees in the elder care sector are well protected and know how to protect those they care for. It is also crucial to ensure that the Working Environment Authority is involved in preparing national guidelines about how to prevent people from infection with communicable diseases. The WEA also needs to ensure that employers take adequate measures to prevent infection. Other important tools include clear guidelines, tailored risk assessments and risk management at the workplace level. Robust monitoring is needed to ensure adherence to guidelines and the ability to carry out risk management at all levels. Important data includes gender-disaggregated sectoral and occupational data on infection, morbidity and mortality. The health authorities and the Working Environment Authority also need to more strongly prioritize ongoing and close contacts with unions that organize key workers on the corona frontline. Unions can create a link between workplaces and authorities. We can raise awareness of issues that prevent key workers from carrying out their work in a safe manner. We can also help communicate official guidelines. For a deeper understanding and for inspiration, we would like again to draw your attention to the contributions on COVID-19 risk management at the workplace, fear of infection and fear of transmission of infection among frontline employees published by the University of Copenhagen and FOA. They clearly show that COVID-19 risk management outside the hospital sector should be addressed and prioritized as part of the public strategy for handling this and future pandemics. – A tripartite agreement about a test strategy – Proper guidelines for visits to care homes. When care homes started permitting visits from relatives again, we worked to ensure clear guidelines and sufficient staff resources(FOA 2020a). Finally, we also find it important to focus on positive lessons learned. For instance, some of our members have experienced greater self-management and better collaboration between colleagues during the pandemic. Their key task has been clearer and they have experienced greater acknowledgement of their skills and contribution. CONCLUSIONS The Danish lockdown in the spring of 2020, and the government’s subsequent restrictions saved many lives of older people dependent on elder care. Nonetheless, by March 2021 we had seen 923 deaths in care homes. The health authorities acted fast and introduced infection hygiene guidelines, but they did not include clear guidelines on occupational safety and health(OSH). During a pandemic we need a strong focus on occupational safety and health. Biological, psychosocial, and ergonomic hazards are prevalent, e.g. fear of being infected or infecting others, increased time pressure, enhanced workloads and insecurity.

References 5 REFERENCES Danmarks Statistik(2021): 59 pct. flere over 80 år i 2030, https:// www.dst.dk/da/Statistik/nyt/NytHtml?cid=30674(23.03.2021). FOA(2020a): Hjælper- også når der er corona. 9 solide sejre, https:// www.foa.dk/forbund/temaer/a-i/corona-virus/foas-indsatser-under-pandemi(16.03.2021). FOA(2020b): Værnemidler, test og retningslinjer i forbindelse med covid-19 epidemien, https://www.foa.dk/forbund/presse/rapporter-un�dersoegelser/medlemmer/2020(16.03.2021). FOA(2020c): Historiske problemer med at skaffe uddannet personale: Hver femte ansatte i ældreplejen er ikke-uddannet, https://www.foa. dk/forbund/presse/seneste-pressemeddelelser/global/news/pressemeddelelser/2020/november/hver-femte-ansatte-i-aeldreplejen-er-ikke-uddannet(30.11.2020). Nabe-Nielsen, Kirsten; Juul Nilsson, Charlotte; Juul-Madsen, Maria; Bredal, Charlotte; Preisler Hansen, Lars Ole; Hansen, Åse Marie(2021): COVID-19 risk management at the workplace, fear of infection and fear of transmission of infection among frontline employees, in: Occupational& Environmental Medicine, 78, pp. 248–254, https://oem.bmj.com/content/oemed/78/4/248.full.pdf(30.11.2020). Statens Serum Institut(2020): Ugentlige opgørelser med overvågningsdata, https://covid19.ssi.dk/overvagningsdata/ugentlige-opgorels�er-med-overvaagningsdata(16.03.2021). Statistikbanken(SCB) 2020: OFF26: Offentlig forvaltning og service, forbrugsudgift, https://statistikbanken.dk/OFF26(21.03.2020). Sundhedsministeriet(2020): Ældretopmødet 2020, https://sum.dk/ temaer/aeldretopmoedet-2020(30.11.2020). Sundheds- og Ældreministeriet(2020a): Bred aftale om hjælp til ældre under coronakrisen, https://www.regeringen.dk/nyheder/2020/ bred-aftale-om-hjaelp-til-aeldre-under-coronakrisen/(30.11.2020). Sundheds- og Ældreministeriet(2020b): Bekendtgørelse om krav om mundbind m.v. i sundheds- og ældresektoren samt på visse dele af socialområdet i forbindelse med håndtering af covid-19, https://www. retsinformation.dk/eli/lta/2020/1533(30.11.2020). Sundhedsstyrelsen(2021): Sundheds-og ældresektoren samt indsatser til socialt udsatte, https://www.sst.dk/da/corona/Information-tilfagpersoner/Sundheds--og-plejesektoren(16.03.2021).

Friedrich-Ebert-Stiftung The Friedrich-Ebert-Stiftung(FES) is the oldest political foundation in Germany with a rich tradition dating back to its foundation in 1925. Today, it remains loyal to the legacy of its namesake and campaigns for the core ideas and values of social democracy: freedom, justice and solidarity. It has a close connection to social democracy and free trade unions. FES promotes the advancement of social democracy, in particular by: – political educational work to strengthen civil society; – think tanks; – international cooperation with our international network of offices in more than 100 countries; – support for talented young people; – maintaining the collective memory of social democracy with archives, – libraries and more. IMPRINT © FES Nordic Countries 2021 Dr. Philipp Fink The views expressed in this publication are not necessarily those of the Friedrich-Ebert-Stiftung and the partner organisations for this publication. Commercial use of all media published by the Friedrich-EbertStiftung(FES) is not permitted without the written consent of the FES. Cover photo: Fredrik Sandin Carlson Design / Typesetting: pertext, Berlin| www.pertext.de

Covid-19 has uncovered many societal fault lines. The virus hit the elder care sector in many countries especially hard, leading to many deaths and pushing care workers fighting on the corona frontline to the end of their limits. The pandemic has underscored deficiencies in elder care that have been warned about and protested by trade unions for years. Precarious working conditions, understaffing and underfunding devastatingly undermined the ability to protect the most vulnerable during the corona pandemic: our elderly. It is high time we listen now. The Friedrich-Ebert-Stiftung has, on the initiative of the Swedish municipal workers’ union, Kommunal, and the Swedish progressive thinktank Arena Idé, commissioned reports from several European countries. By focusing on the plight of those in need of care and their caregivers, the reports shed light on the pandemic’s impact on elder care and highlights the justified demands of the care workers’ trade unions as well as the long overdue need for reform of the sector as a whole. Further information on the project can be found here: www.fes.de/en/on-the-corona-frontline