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During the 1990s several kinds of reorganization has taken place in public services in Sweden. Reorganizations according to the idea of market economy have been most salient and debated. In many municipalities private companies have started to organize home care service for elderly, financed by tax. Public home care organizations have reorganized the working organization and managing structure, partly to save money and partly to reach better quality of care. The home care services have a key role in the care of the elderly in the society. The quality of care is important for the possibility for elderly to stay as long as possible in their ordinary homes. We have performed a longitudinal study of the reorganizations during the 1990s in order to explore the consequences for quality of care. The study was performed in seven districts in three different municipalities representing different types of municipalities and different kinds of reorganizations. It comprises private companies, traditional public organizations, public organizations with changed managing structure and co-ordination of home help and home health care. Quality of care is studied through assessment of the communication in the organization, the psychosocial working environment of the caregivers and the quality of the care work. Politicians, managers, ca. 100 care givers and ca. 500 elderly receiving help and care have been interviewed four times during the period (1993, 1995, 1997 and 2002/2003). The traditional organization within small districts with small autonomous working teams and easy accessible supervisor expose the best quality. There are no unambiguous differences between public and private organizations. There is however a tendency for successive decline of quality for private companies after they have been established. Other aspects of the reorganizations, e. g. to have special officials for assessment of help need, do not contribute to better quality but create new communication gaps in the organization and have negative influence on the working environment. Stability in the composition of the care worker teams, leadership, decision-making processes in the organization and the district area promote high quality of care. The reorganizations during the 1990s seem on the whole to function contrary to promotion of high quality in the care and service for the elderly.

The family with the elderly and the home help workers’ team constitute two organisations, which meet in the care work. In this context the family is extended and often constitute not only members from the nuclear family but also other members of the network of relatives, whom take part in the care of the elderly. The extended family may in some cases include four generations (Finch & Mason, 1993). Home-help for elderly people have expanded in Sweden during the period 1960 - 1980. This was due partly upon the prevailing ideology that it is important for frail elderly to stay in their own homes. Due to this expansion the local communities have developed their public home-care organisations. Different kinds of autonomous group organisation predominate (Olsson et al, 1995). Small work groups take responsibility for home help service in local areas. Home-helpers organise their job themselves, exchange experiences and give each other emotional support. In Sweden both home care and institutional care of the elderly has decreased during the 1980th and 1990th in spite of the fact that the proportion elderly over 80 years (4,5 % of the total population) has increased 60 % since 1980. Twenty-two per cent of the women and 16 % of the men over 80 were cared for in their own home 1996. This development is said to have caused relatives to care for their frail elderly in the homes side by side by the home help services in an increasing degree (Johansson, 1991; Szebehely, 1998). Public care and service has an important impact on the interaction pattern between family members (Hendriksen, 1989; Johansson, 1999; Bass m fl, 1999). Home care may serve as an intervention that influences the health, well-being and life quality of the elderly and other family members. This intervention may have positive as well as negative effects. Problems and conflicts may arise in the interaction between the family members and between the family and the public help services (see McGoldrick & Gerson, 1989). We need more knowledge about these processes. In a research project1 the family and the home help services are studied as two organisations, which interact in the care of the elderly. We start with the hypothesis that the relation between the parties will have an impact on the character and quality of the care. We also think that the quality of the interaction will have an impact on the health and wellbeing of the elderly (see Olsson, 1991, 1998; Olsson & Ingvad, 1999).