"Only seeing the numbers and forgetting the people behind" - The influence of New Public Management on elderly care : A country comparison between Germany and Sweden

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School of Health, Care and Social Welfare

”ONLY SEEING THE NUMBERS AND

FORGETTING THE PEOPLE BEHIND”

- THE INFLUENCE OF NEW PUBLIC

MANAGEMENT ON ELDERLY CARE

A country comparison between Germany and Sweden

DENISE SOYKA

Main Area: Social Work Level: Second-cycle level

Credits: 30 higher education credits

Programme: Master’s Programme in Social

Work within Health and Social Welfare

Course Name: Thesis in Social Work Course Code: SAA062

Supervisor: Anna-Lena Almqvist Seminar date: 2021-06-04 Grade date: 2021-06-14

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“ONLY SEEING THE NUMBERS AND FORGETTING THE PEOPLE BEHIND” - THE INFLUENCE OF NEW PUBLIC MANAGEMENT ON ELDERLY CARE: A COUNTRY COMPARISON BETWEEN GERMANY AND SWEDEN

Author: Denise Soyka Mälardalen University

School of Health, Care and Social Welfare

Master’s Programme in Social Work within Health and Social Welfare Thesis in Social Work, 30 higher education credits

Spring term 2021

ABSTRACT

The elderly care sector is facing high demands in the context of demographic change. In regard to the high potential of efficiency increase, the area has been restructured particularly strongly based on principles of the New Public Management (NPM) since the 1970s. This thesis aims to investigate the influences of NPM on elderly care and the effects on care staff and people in need of care by means of a qualitative approach based on a qualitative content analysis. Through a holistic perspective, the role of social work as a profession and possible changes within the welfare state structures of Germany and Sweden is explored. The findings convey a rather negative experience of the impact of NPM and is characterized in both countries by a high degree of privatization, standardization and economization in care. Due to higher workloads and fewer resources, the pressure on staff in care is high. In addition, services for those in need of care are reduced and the quality of care suffers from the staff’s high workload. The objective of care is affected by the implementation of NPM and entails a change in the profession, which needs to be viewed critically based on the results.

Keywords: Elderly care, Germany, New Public Management, qualitative content analysis, Sweden

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1 INTRODUCTION

Since the 1980s, the elderly care and long-term care insurances (LTCIs) are in constant restructuring and the regulations and provision are reorganized within Europe. However, the reform changes of the 1980s are mainly characterized by neoliberal principles, which started to emerge in the 1970s. Thereby, the concept of New Public Management (NPM) has established itself as a term, by which market-like economic principles are intended to avert the economic crises by efficiency increase and simultaneous improvement of public services, according to the maxim “Do more with less” (Hood, 1995, p. 96). Despite different implementations of NPM within the countries, it has gained great prestige and has thus had a significant impact on the transformation of public services and hence on the care of the older adults.

The area of elderly care is becoming increasingly relevant, especially in the context of market globalization, demographic change and societal shifts, such as in family structures (Auth, 2012). Accordingly, the old-age dependency ratios of Germany and Sweden in 2019 were above the EU average of 31,4% (Eurostat, 2020). At the same time, medical care and general living conditions are improving. In connection with societal changes, birth rates are decreasing while life expectancy keeps increasing (Heintze, 2015). According to this, the share of the global population over 65 years of age will increase from 8% to 16% in the years from 2010 to 2050, thus doubling. This trend also applies to Sweden and Germany (Euler Hermes, 2012). Due to the high need for action to meet current and future needs, the area of elderly care has a particularly high potential to increase efficiency in the context of NPM. By the resulting major influence of NPM on the elderly care, impacts and changes in the area of management as well as with regard to the profession and its identity are to be captured (Kamp & Hvid, 2012). With statements such as "Care crisis: the conditions in care are inhumane" (Hoffmann, 2020) and “Elderly care on an uphill struggle” (Lindgren & Lindstedt, 2020), is the precarious situation in elderly care in Germany as well as in Sweden illustrated and refers particularly to the high staff shortage and workload, which became especially apparent in the present event of the pandemic.

Using a methodological qualitative approach, this thesis will investigate the different implementations of NPM in Sweden and Germany and examine their influences on care. The effects on the staff as well as on the people in need of care will be investigated and assessed as regards the quality of the services and consequently the quality of life. In order to get a holistic

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understanding of the situation and to explore the implications for social work, not only different professionals in the field of elderly care will be interviewed, but also representatives of social work associations in Sweden, the “Akademikerförbundet SSR” and in Germany from the “Deutsche Berufsverband für Soziale Arbeit” (DBSH). In view of the different welfare state structures of the two countries, the findings are intended to indicate conclusions about possible changes in care provision structures as a result of the influence of NPM. In this respect, Sweden classifies itself as a social democratic welfare state with universalistic and generous benefits, while Germany is a rather conservative welfare state and is very much based on the family system according to Esping-Andersen (1990).

Accordingly, after the formulation of the aim and research questions, the theoretical perspective of welfare state theory will be presented. Thus, a broad and fundamental framework is provided in order to subsequently position the previous research of the care structures of Germany and Sweden in the welfare systems. This is followed by the previous research regarding NPM with reference to the area of care. As such, the broad welfare structures will be narrowed down to the structures of elderly care and NPM. Whereupon the method and material, the resulting findings and analysis as well as subsequent further discussion follows, with a final conclusion.

1.1 Aim and research questions

This thesis will explore the professional's experience of the implementation and influence of NPM in the field of elderly care. Structural transformations as well as effects on the quality of care will be examined. Furthermore, the impact of NPM in elderly care is to be analyzed in relation to social work as a profession. The following research questions are to be answered in this thesis: First, how do professionals in elderly care experience the implementation of New Public Management? Second, how do professionals in elderly care perceive the influence of New Public Management related to professional caregivers and older adults in need of care? Third, how do professionals in elderly care and representatives of Social Work associations experience the effect of New Public Management on Social Work as a profession?

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2 THEORETICAL PERSPECTIVE

NPM is often referred to as the new way of public service management, as it aims to provide cost effective, reliable, and market-adjusted services (Heffernan, 2006). This thesis aims to illuminate a cross country comparison through the lens of NPM and its influence on elderly care in the two countries; Germany and Sweden. The welfare state structures will be examined in both countries, as it could potentially reveal the differences of elderly care from a theoretical and practical perspective. Thus, welfare state theory is addressed as the theoretical perspective of this thesis in order to provide the framework to classify the influence of the NPM.

Titmuss, one of the earliest pioneers of social welfare has laid the foundation for the characteristics of social policy 60 years ago (Natali & Pavolini, 2018). Along with the social welfare (benefits provided by the state), Titmuss further identified the fiscal welfare, which includes the tax incentives, as well as the occupational welfare, in which services are provided by social workers (Natali & Pavolini, 2018). Access and provision of social services as well as equal rights, Titmuss has analyzed other approaches that are applicable to a welfare state, such as selectivism and universalism (Titmuss, 2014). Esping-Andersen has developed a typology, in which welfare states are dependent upon three principles; decommodification, social stratification and the private-public mix (Bambra, 2007).

2.1 Welfare state – selectivism vs. universalism

Due to technological advancements and industrial progress, the environment and society has been changing rapidly. Consequently, the impact of postmodernism and conflicts between economic and social welfare, allocated resources and economic growth have more importance than ever before, which gives rise to limited resources, insecurity and social inequality (Titmuss, 2014). Different classes and parts of society need to stand for the costs to compensate for the loss and it’s the welfare states responsibility to provide additional benefits when needed. Given the power of welfare states to provide benefits, they can likewise facilitate social inequalities (Reisman, 2001). Through selectivistic and universalistic principles, the welfare state can determine its power. Individual needs assessments for social services, as selectivistic principle, might disadvantage the people who are in the most need, as middle-class fits the selectivistic criteria better. Therefore, selectivistic characteristics can create social inequality as benefits for socially disadvantaged groups can be denied. Moreover, the use of social assistant is accompanied with stigmatization (Titmuss, 1968). On the contrary, the universalist approach promotes the more democratic approach; providing the same benefits for all. To treat everyone equally could withdraw the effects of stigmatization. Even though, the gap between

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different demographic groups cannot be decreased as the approach of universalism wouldn’t suffice. By giving the same treatment to everyone, the convergence between rich and poor is still non-existent. However, applying the universalistic approach implicates a step towards social justice, stigmatization can be reduced (Titmuss, 1968). Marshall’s (2014) theory of social citizenship gives equal rights to all citizens. While civil rights had been introduced in the 18th century and political rights in the 19th century, there is a continuous development for the rights of citizens. With the establishment of social rights in the 20th century, social welfare benefits and institutional rights, such as access to education have been provided. Therefore, the rights of citizens intend to provide the same rights and access across different social and demographic classes (Marshall, 2014). Even though answers to questions about how the elimination of stigmatization and the approach of social justice could be eliminated are still contradictory, as people are treated differently and equally at the same time (Reisman, 2001). To lay down a foundation, the key to universalistic rights is to remove stigmatization, thus a selective approach can be converted to give the rights to those who need it the most. Titmuss further details that positive discrimination, reversing negative selection by positive and providing additional resources, could avoid the danger of stigmatization as it aims to reach an optimal standard rather than a minimal (Wong, 1998). Universalistic approach could potentially eliminate personal relations to the recipient of services as detailed need assessments would result in same benefits and same rights. On the other hand, the need for personal contact with the recipient is key regardless of which approach one uses. There needs to be a long-term solution that aims to treat people equally, to provide equal rights and to eliminate injustices. Cash benefits to be granted, alone, will not be the solution (Reisman, 2001).

In context of the universalistic approach, the principles of economy and the benefits of the welfare state are in competition with each other and thus, for example, social assistance is a negative cost factor in the perspective of economy. The universalistic approach entitles all citizens to benefits, even if they do not need them to the same extent. Although the universalistic principle brings desirable elements to a welfare state, it competes with economic interests, which argue it to be a costly investment and ineffective by itself. Therefore, the pursuit of a compromise between these two contradictory approaches is a complex matter that needs to be negotiated (Titmuss, 2014). The challenge within the universalistic foundation is to create a foundation that takes into account the right of every person for welfare state benefits and to provide adjusted need assistance for individuals that are in the socially disadvantaged groups of society. Through fundamental principles and values, such as social justice, the ultimate goal for the state is to pursue an effective and economically efficient system (Titmuss, 1968).

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2.2 Three models of the welfare state

Titmuss had identified three models of the welfare state, which were namely “residual, institutional redistributive and industrial achievement-performance states” (Aspalter, 2011, p. 736). Titmuss’ work shifts away from the contemporary theories, as he emphasized the ideological differences of welfare states. While the level of economic development was the main focus of previous ideologies, it's the policy of choice that determines the welfare state according to Titmuss (Noyoo, 2017). The key objectives were to identify and underline the system, principles and effects of a welfare state in order to be able to draw comparisons between the concepts of different welfare states. The models are embedded into an ideal model, as it does not distinguish the in-depth differences, it serves as foundational principles of the states. Both, Titmuss and Esping-Andersen, have been inspired by Marshall and his theory on social citizenship (Aspalter, 2011; Glennerster, 2001). By having the Western industrialized nations in the main focus, political formation and coalitions were the main explanations that have shaped the welfare states. Consequently, previous social policies had influence to a great extent on the institutionalization of social classes. Esping-Andersen further emphasizes the institutionalized models of the welfare system, as previously established structures - such as pensions systems - cannot be simply changed. To change an existing structure and system radically would require the respective population classes to pay for the pensions of elderly people as well as for their own future pensions. This is described as a dependency by Esping-Andersen which has grown from political structure and reforms that have an impact and influence of the present state (Esping-Andersen, 1990).

The different interactions with the welfare state can be demonstrated by a triangle of state, market and family (Esping-Andersen, 1990). These factors are interdependent with the state being the focal part and be in major importance to social assistance. Through the dimensions of decommodification and stratification, the welfare state can be further characterized according to Esping-Andersen. In this context, decommodification is higher as people are more independent from the market (Esping-Andersen, 1990). Decommodification is contingent upon the sale of the labor power. Esping-Andersen argued that the decommodification strengthens the workers, however, it weakens the employer’s authority (Noyoo, 2017). Furthermore, as workers are independent from the market and thus the livelihood is secured, decommodification occurs. On the other hand, however, if workers are relying on the market, their livelihood is not secured and social benefits are not provided, decommodification is lower. As a consequence, market dependency is characterized by inequalities, as employers have the power (Esping-Andersen, 1990). The goal of decommodification is to maintain a balance of power relations between the employees and the workforce in order to counteract injustices. While employers’ aim is to claim this power to secure economic advantages, social welfare aims to maintain social relations and social

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equality (Esping-Andersen, 1990). Social stratification is the extent in which a welfare state excludes or favors certain groups or social classes. As a result, social exclusion is promoted and the basic income support services are characterized by stigmatization (Esping-Andersen, 1990).

Inspired by Titmuss, in the book of “The Three Worlds of Welfare Capitalism” (1990), Esping-Andersen developed three models of welfare regimes. The social democratic welfare state is based on universalism and simultaneous focus on individuals’ needs. In this type of welfare states, there is a high quality of social benefits as they are generous and egalitarian, as well as there is a high degree of decommodification. Consequently, tax rates are high to be able to economically provide high benefits, as well as employment rates are high, which further results in reduced social problems. The social democratic welfare states promote gender equality, such as equal employment opportunity for both men and women. Equality is further present in society as it aims to minimize social disadvantage and pursues to provide high standards for the middle class (Esping-Andersen, 1990). These types of welfare state regimes are the Scandinavian countries, such Norway, Sweden, Denmark and Finland (Esping-Andersen, 1990).

The liberal welfare state is characterized by individual freedom, and a free market that enables individuals to realize their own potential without the exposure to pre-existing hierarchies (Noyoo, 2017). Society as a whole has the freedom and responsibility to earn their own living and to consequently provide social security, such as private insurance, consequently they are dependent on the market (Esping-Andersen, 1990). Decommodification in liberal welfare states are low, and as a consequence of labor market dependence and lack of state intervention, there is a high degree of stratification in society. Example of the liberal welfare state are countries like Great Britain, Ireland, United States, Canada, Australia and New Zealand (Noyoo, 2017).

The conservative welfare state is characterized by social hierarchy and status. Entitlements and rights are related to class and - among other factors - determined by the private insurance system and the marginalized benefit system. Countries that are characterized by this conservative regime are Germany, France, Italy and Austria. These countries are often times referred as stratified by occupational status and income level (Esping-Andersen, 1990).

2.3 Additional feministic perspective

While Titmuss focused on social policy in his theory on the welfare state, Esping-Andersen compared welfare states from a wider perspective. Besides differences of opinion on

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the different models, Titmuss and Esping-Andersen have a common critique of gender roles, unpaid care work and the role of the family. Both addressed some aspects of these issues, but integrated them only marginally or not at all in their theories (Glennerster, 2001). Esping-Andersen (1999) referred to this criticism and added a new model of the welfare state for the Southern European countries. Furthermore, Esping-Andersen focused in his book "Incomplete revolution: Adapting welfare states to women's new roles" (2009) on the role of the family and gender equality in terms of social inequalities, as well as related to the aging society. However, according to Orloff (2009), Esping-Andersen's work still contradicts with the deeper implications of feminist labor and faces challenges in assimilating concepts such as care, power related to gender and interdependence, and thus requires further comparative welfare state studies based on gendering.

Cousins (2005) addresses this very link between the welfare state and gender and makes the importance of this issue explicit for welfare state structures and the state. Gender conveys different conceptions of the roles of men and women in public, professional, and private contexts. As well as in Titmuss and Esping-Andersen, this topic was hardly dealt with because of the male population being selected as the addressee. However, especially in the welfare state, women play a decisive role. With the aspect of the numerous successful women's organizations, a gender-specific perspective is included on the basis of Cousins (2005).

There are differences in the use of and the benefits provided for women and men. For example, not only salaries vary, but so do the figures for claiming unemployment insurance at parental leave. In addition, the role of the money earner plays a crucial role with respect to the welfare state. Thus, with the traditional "male-breadwinner model", women are dependent on marriage and men, with corresponding tax regulations and benefits to encourage women to stay at home with the children, this concept is reinforced and can rather be ascribed to conservative welfare states (Cousins, 2005, p. 59).

In contrast, in the last few decades there has been a movement, including the European context, to promote equality between men and women. As a result, there has been a tendency towards the “dual earner model”, which is embodied in the social democratic welfare model (Cousins, 2005, p. 62). At the same time, measures such as the expansion of childcare have generated a workforce in the public sector and increased the female labor force participation rate. Thus, the Scandinavian countries, with their well-developed childcare system and appropriate benefits for both parents at the birth of a child, stand for very high female employment. As indicated in the previous chapter, this is essential in order to finance the good childcare and benefit system. As a point of criticism, it can be noted that women's employment is predominantly located in the public sector, and thus a distribution of occupation-specific gender roles to the private sector is still identifiable. Consequently, a pay gap is in control, in

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which the public sector cultivates lower salaries and the male-dominated private sector prospects for higher salaries. In the countries with dominant male-breadwinner model, there have been discussions about compensating the care work of mothers with their children or the elderly (Cousins, 2005). Thus, there are approaches to value the care of mostly mothers and to compensate them in various forms of allowances in these countries. However, this approach does not aim for gender equality (Cousins, 2005).

3 ELDERLY CARE STRUCTURES IN GERMANY AND

SWEDEN: PREVIOUS RESEARCH

In order to contextualize the results of the empirical data, as presented later in this thesis, the welfare systems and structures of care for the older adults in Germany and Sweden are presented subsequently. Thus, connections between the theoretical aspects as well as the qualitative findings can be drawn and discussed in the later course of the thesis.

3.1 Germany as a conservative welfare state

According to Esping-Andersen’s model of the three welfare states, Germany is referred to as a one of the conservative welfare states. The country’s family-based system is characterized by conservative beliefs and subsidiarity is oftentimes implied as a foundational principle (Esping-Andersen, 1990). Germany provides a range of social risk benefits, such as public health insurance, LTCI as well as unemployment insurance (Bonoli, 2007; Auth, 2012). Referring to Adenauer’s pension reform from 1957, Germany is considered one of the “pioneers of social insurance”, as the country provides coverage against social risks, such as providing income replacement benefits in order to increase economic security to labor market participants, however, it does not indicate a high level of decommodification (Esping-Andersen, 1990, p. 22). On the contrary, the foundation of the German insurance system is embedded into rules and conditions of employment (Esping-Andersen, 1990).

Since the 1990s, there have been two main pathways identified for the European market trends in long-term care (LTC) (Ranci & Pavolini, 2015). A residual long-term care model is characterized by a universal approach as it aims to expand the scope of and resources assigned to care. Countries that fall under this model are Germany, France, Spain and Italy. The second pathway includes the Scandinavian countries and England with its already established universal LTC, however, it has since changed its direction towards a restricted

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universalism. This means that countries with less developed LTC models expanded and universalized, while countries that were already well developed and had a universal model had the opposite tendency and therefore restricted it (Ranci & Pavolini, 2015).

Social inequalities are oftentimes created by public and private insurance as the benefits are provisionary (Esping-Andersen, 1990). Additionally, those who are able to afford private insurance coverage are the ones that are extensively covered in case of loss or inability of employment as well as by exiting the labor market earlier (Esping-Andersen, 1990). Germany has a so-called civil service system, that is a form of public employment and is based on the public law. This group entails judges, soldiers and public administrators (Wegrich et al., 2018). These individuals have a unique position and benefit as servants in the civil service. The debate still remains whether this form of mutual partnership is a symbol of the traditional orientation of Germany (Esping-Andersen, 1990). A family centric view is rooted into Germany’s traditional values. The responsibility of families is high and indicates a high level of inequality of social opportunities in relation to the family of origin. These family-related social disadvantages would, therefore, need to be balanced by the welfare state (Böhnisch & Schröer, 2016). To be mentioned, there is a 19,2% gender pay gap which further advocates inequality in the society (Eurostat, 2021). Additionally, the employment of women is oftentimes marginal or part-time employment, which further promotes dependencies on marriage or, stated differently, in most cases on men. There is significant data-based evidence on the tax advantages that can be claimed through marriage, which further emphasizes the relevance of “male breadwinner model“ (Cousins, 2015, p. 60).

3.2 The German care system

The German Social Services Act “Sozialgesetzbuch” (SGB) XI (1994) is the legal basis for the benefits and entitlements of the social LTCI that is regulated nationally. In this regard, the entitlement to LTCI is not universal, but is tied to employment (Auth, 2012). These services are provided and offered by private and public insurance companies. In Germany, social services are regulated by the federal states, while the LTCI is based on law, hence, regulated consistently throughout the entire country. Educational and child care, on the other hand, services and regulations are oftentimes differ between federal states. According to SGB XII (2003), LTCI only serves as a partial insurance and supplemented by asset-based and means-tested subsidies. However, it violates the principle of solidarity, which refers to an equally shared benefit and obligation between members of society. As an example, the “Riester-Rente” is a form of private capital and investment and the “Pflege-Bahr” are additional coverages that can be subsidized. As a consequence, public and private insurance are present in the LTCI. The

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LTCI system operates on a legal basis with a narrow concept of need for care based on basic care and housekeeping. In the assessment of the need for care, those in need of care are categorized into care levels and benefits are granted accordingly. Since LTCI is only partial, the informal care sector in Germany constitutes an alternative for many people in later life (Heintze, 2015).

With the introduction of the provision of care by the LTCI, the municipalities are still responsible for ensuring the necessary care structures. Furthermore, supply structures can depend and vary based on the interest of different municipalities (Brüker et al., 2017). Within municipalities, support centers have been established and are aimed to consult and to identify gaps within local care provision (Bode, 2016). These centers are the bridge between LTCI, non-profit organizations as well as volunteer groups and serve as an operating and control element of specific regions. Additionally, these centers are further involved and accountable for the coordination of different services within municipalities. However, functionality wise, these centers only provide consulting services and do not hold the rights of identifying and developing the regulations of municipalities (Brüker et al., 2017).

Germany puts a high priority on family and is a family-centric country. However, as a country it experiences a steady decline in family structures (Neubart, 2017). The lower birth rates, but higher life expectancy with an increased divorce rate are key components of the changing family structures. Due to urbanization, both family as well as health resources decrease. Consequently, there is a higher rate of loneliness, particularly in the older age, and poverty, as adequate supplies are not accessible (Neubart, 2017). This gives rise to low psychological and emotional well-being which results in an unsteady state of being. Poverty in old ages means that one’s income is 60% less than the average, and it affects 12% of people that are over 65 years of age (Neubart, 2017). In relation to the increased vulnerability and therefore increased loneliness in old age, especially in care homes, professional caregivers are particularly involved and of high importance in counteracting loneliness and meeting social needs, which are equally crucial for their health as the study of Sya’diyah et al. (2020) shows. In Germany, the promotion of home care is a key element in the development of care structures. The pursued objective is to establish steady conditions for elderly, to receive care in their homes rather than being admitted into high-cost care facilities. To receive care at home can result in better psychological well-being and longer life expectancy (Brüker et al., 2017). Thus, the support of home care is pursued by both economic interests and qualitative aspects of care. The guiding principle “outpatient before inpatient” therefore strives to activate human potential and empowerment including within family care (Auth, 2012, p. 621). Additionally, it further influences the infrastructure of municipalities, as the care system is embedded into care insurances and non-profit institutions. However, in order to support home care, there

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needs to be a collaboration between institutions to provide care and support older adults and family caregivers (Brüker et al., 2017).

However, many families lack confidence in professional care, especially residential care. Due to the shortage of skilled workers, Germany must increasingly rely on unskilled nursing staff. With a rising need for care of around 50% by 2030, there will be a shortage of around 500,000 full-time staff. Care has a bad image and recruitment of care workers from abroad may lead to additional language barriers (Neubart, 2017). According to the article by Rohwer et al. (2020), care work in Germany is characterized above all by high work intensity and time pressure. This arises from the work intensification of increased demands in the same amount of time. As a consequence, this has a negative impact on the health of the nursing staff and deficiencies in the quality of care are the result. However, according to Woods' article (2014), the relationship with professional caregivers in particular is considered to have a positive impact on the quality of care from the perspective of those in need of care, but the time is too short. In order to improve the image and the education within the care sector, the generalistic care education was introduced in 2020, which aims to attract more participants who will specialize in the care of the elderly during the course of their education (Roes, 2014).

In addition, there are numerous providers in Germany, resulting in a strong economic focus by the private providers, especially in the residential area. Due to the cash-for-care principle of LTCI, the benefits have been calculated in a catalog of services. As a result, care personnel are prescribed the time they are allowed to spend on the respective activities and are then compensated accordingly. Due to the service catalog, the work density in care has increased in order to still be able to bring economic success. Consequently, the informal care market is being used and the poor working conditions are an essential factor in the shortage of skilled workers (Bode, 2016). Additionally, are the care services characterized by high documentation efforts, resulting in 14% of all LTCI expenditures and thus 2,7 billion € per year (Schlitz, 2015). Ultimately, there are gaps in care due to a lack of personnel, which in turn leads to deficiencies in quality. But as family structures decline, the demand for professional care will continue to rise and become even more precarious, and the family care model will be exhausted (Heintze, 2015).

3.3 Sweden as a social democratic welfare state

Referring back to Esping-Andersen's typology (1990), Sweden is categorized as a social democratic welfare state as a consequence of egalitarian rights and benefits for its citizens. Traditionally, the Nordic countries, such as Sweden, Norway, Finland, Denmark and Iceland, have publicly funded coverages, for example healthcare and unemployment benefits, however,

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there are significant differences between these countries and therefore cannot be generalized by the Scandinavian model (Hilson, 2008).

The universalist approach does not just promote equality and social security, it tries to focus on the individual. While the underlying conditions are same for everybody, situations and needs can be adapted to individuals in order to maximize the services available (Hilson, 2008). The state takes responsibility and accountability for elderly care, children care and care for people in need and emphasizes older adults as full and equal members of society (Jönson & Harnett, 2015). This is related to Marshall's theory of social citizenship rights (Marshall, 2014). The welfare state was shaped in particular by Sweden's social democrats. As such, they also initiated measures such as the introduction of for-profit companies into the public sector. However, the population has taken a rather critical stance towards privatization and profit-making, and is more committed to the public sector. In this context, Sweden's unions, which have been influential in shaping the welfare state, have tended to be less active in advocating against the privatization of the public sector (Meagher & Szebehely, 2019). Additionally, the Swedish Insurance Agency (Försäkringskassan) provides benefits and monetary help for parental leave or for sick leave (Försäkringskassan, n.d.). Furthermore, unemployment benefits are registered through another entity, called A-kassa, which administers the number of benefits based on previous income (Svergies a-kassor, n.d.).

All these services promote freedom and stratification. On the contrary, already vulnerable groups, such as those living in poverty and single parents, do not have the opportunity to enjoy the same rights and benefits. As a result, stigmatization and social inequalities are present and fades away from the social democratic principle. The degree of benefits, however, depends on previous employments, and insurances are having strict measures based on tenure and income level. To be able to have the right for social and unemployment benefits is a consequence of a high employment rate and good integration in the labor market (Kuivalainen & Nelson, 2012).

Women's presence in the labor market have been increasing in the past decade and therefore care system and maternity benefits have been reformed. Paternity leave benefits are equal between men and women, and as a result the status quo and biases have been challenged. Thus, the dual breadwinner model can be pursued in the Swedish context (Cousins, 2005). Within the universalist foundation, the concepts of socialism and liberalism can be identified. Overall, the social welfare structures as well as the high employment rate are the basis to ensure the welfare system and its generous benefits (Hilson, 2008).

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3.4 The Swedish care system

The legal basis of care for the elderly and the accompanying regulations on care are laid down in the Swedish Social Services Act, known as "Socialtjänstlagen" (SoL). Thus, the SoL forms the basis for the actions of the municipalities in the care for people in later life. The responsibility lies with the municipalities, which also implies variations in interpretation and execution, and hence differences in the quality of care between municipalities (Trydegård & Thorslund, 2010; Yeandle et al., 2014).

According to the §§ 1 and 2 in the 5th_{chap. SoL (2001:453) and the §§ 4-6 in the 6}th_chap. SoL (2001:453), the legal basis provides only broad outlines of the values to be conveyed and the services to be provided and gives the responsibility to the municipalities, which can act independently from each other. Ultimately, the municipalities decide on the quality and scope of the care for people in later life in Sweden. However, there is also financial pressure on the municipalities. In order to retain decision-making authority, the municipalities are required to a certain extent to keep costs as low as possible (Heintze, 2015). According to § 1 in the 4th_chap. SoL (2001:453), the right to support is specified and includes the entitlement to support if the needs cannot be met. This is intended to ensure an adequate standard of living, although financial resources are not included in the assessment of support. Merely the contributions to be paid, respectively fees of the services, are regulated in the 8th chap. SoL (2001:453) and depend on the own financial means.

Between 1960 and 1990, a reformation in social services took place from the area of child care to care for people in later life in order to ensure public provision and, above all, to support women in the family caregiving and to promote higher participation in the labor force. Policymakers recognized that caring for relatives demands a lot of time and energy and places a heavy burden on unskilled family members (Sand, 2007). This restructuring of care forms the basis of the high labor force participation rate. Thus, the basic framework of high participation in the labor force and enabling the generous benefits is in place. Based on the strong labor force orientation, the legally undefined entitlement for care benefits can be explained and sets the course for formal care (Heintze, 2015). In 1992, the introduction of the Ädel-reform initiated a process of reconstruction of the health care system and transfer of responsibility in providing care to the municipalities (Auth, 2012). If the people in later life do not possess the respective financial means to pay the fee, they are granted a subsidy. In the event of uncovered costs, the family will not be called upon under any circumstances. Thus, the emphasis is shifted away from the family and is directed toward the individual (Heintze, 2015). Based on the European definition of poverty, when income is below 60% of the average income of the population, the share of people over 65 at risk of poverty is 17% in Sweden. Thus, every seventh person over the age of 65 is below the poverty line, whereby particularly people

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born in foreign countries are four times more likely to be affected by the risk of poverty (Statistiska centralbyrån, 2017). As an additional factor in considering people's quality of life in later life, loneliness and anxiety in old age can be identified as an influential aspect. According to Jakobsson & Hallberg (2005), however, the results of different studies show variations in the degree of loneliness. Nevertheless, the correlation between subjective health, gender and increased loneliness and fear could be identified, whereby women were generally lonelier. In the Swedish context, the key factors of well-being, particularly for women, were social relationships, development of self-identity and personal growth. This indicates that well-being is not only based on good physical care, but above all requires support in one's own development and well-being (Svensson et al., 2012).

The role of the family in Sweden constitutes important support for older adults, and especially in minor household assistance the amount of support is growing. In particular, women/daughters are increasingly involved in family care, which may affect income deficits and subsequently their retirement benefits (Thorslund & Wånell, 2006; Jolanki et al., 2014). In the individual assessment by the municipality, the focus is on independence and aging with dignity. No categorization is made, but there must be a minimum level of need for assistance in order to be able to claim the services (Heintze, 2015). According to Titmuss, the individual needs analysis can be considered a selectivistic approach, especially since the services provided to the people in later life vary between municipalities (Titmuss, 1968). However, twice as many people received home care services in the years around 1980 than in 2007, an unexpected trend given the aging population, and can be explained by higher fees, changes in needs assessment, and modifications in the delivery and organization of assistance (Sand, 2007). Despite the de-institutionalization of care, a decline of public services is likewise confirmed by the Szebehely & Ulmanen (2012) and the associated shift of responsibility of care to family or other relatives. However, this can promote social injustice, as not everyone has the private means and resources to compensate for the decline in public services (Szebehely & Ulmanen, 2012). The possible decline in social support can therefore be related to higher loneliness and thus higher risk of dementia (Sutin et al., 2020). While the social costs of dementia are very high in Sweden (Wimo et al., 2016) and are seen as a major global challenge due to the estimated increasing number of cases within the aging society (Winblad et al., 2010).

In Sweden, care is considered a scientific discipline and therefore entails generalized and academic training (Heintze, 2015). However, there is also a lack of skilled workers in Sweden and involves the challenge of maintaining high qualitative standards in care for the people in later life. After all, if the expenses of the welfare state are high and the financial resources in elderly care are low, the result will be a lack of workforce and provision of care (Thorslund & Wånell, 2006; Strandell, 2020). According to Strandell (2020), in addition to difficulties in

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recruitment, the staff are subject to high work pressure and poor working conditions, which are neither well compensated nor appreciated in relation to status. Staff shortages and poor working conditions became particularly apparent in Sweden during the Covid pandemic, reinforced by other factors as lack of protection supplies and hygiene, may led to an increase in the mortality rate in care homes for the people in later life and thus initiating a debate about the conditions in care (Greve et al., 2021). According to the work report, based on a Nordic survey-based study named NORDCARE, by Szebehely et al. (2017), a high dissatisfaction of employees in care can be confirmed and a resignation tendency is suspected.

4 PREVIOUS RESEARCH ON NEW PUBLIC MANAGEMENT

The influence of NPM shaped reforms in public services and administration. Thus, the origins as well as the characteristics of NPM will be identified in order to subsequently apply them to the care structures in Germany and Sweden and Social Work as a profession.

4.1 Public administration and neoliberalism

Public administration was able to assert itself almost undisturbed as a foundation stone for decades until 1970 and, especially in Europe, was oriented on Weberian principles and ideas of bureaucracy (Homburg et al., 2007). However, neither Keynes' economic theory, that dominated the period after the Second World War, could resist the financial crisis nor offer any explanations for the stagflation (De Vries, 2010). Consequently, in the 1970s and the desire for privatization and deregulation, the work of Adam Smith's liberalism from the 1770s resurfaced, which seeks to minimize government intervention in the market and thereby promotes greater trade and economic growth, emerging as neoliberalism (McGregor, 2001). Accordingly, neoliberalism is characterized by the three core elements of decentralization,

individualization and the free market, which is shaped by privatization and deregulation

(McGregor, 2001).

In terms of individualization, the focus is laid on self-responsibility, away from the public or community, whereby the targeting and success is also based on that of the individual. With this assumption, everyone benefits equally and thus social consequences and ideals do not need to be taken into consideration in neoliberal actions (McGregor, 2001). In this context, the principle of the free market is linked to individual responsibility and thus challenges social guidelines that allocate benefits to certain groups in society and pursues more of a

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homogenization of society. In addition, the privatization of state institutions is supported, as well as any actions that save costs through state regulation (McGregor, 2001). In this context, the privatization of public institutions represents the strongest form of commodification and conveys, for example, an image of primarily private care, towards the residual system of the public sector. One of the reasons for the privatization was the reduction of public expenditures, which in turn results in a lower tax rate. However, this has not occurred to the same extent as anticipated, and has only led to indirect taxation and a more regressive system (Connell et al., 2009). However, human, labor and environmental rights are not the focus of the decision-making process (McGregor, 2001). In addition, decentralization is intended to make the administration and the organization more effective, to increase accountability, and to bring the services closer to the recipients in order to meet their needs more accurately (McGregor, 2001).

In addition to political and economic shifts, neoliberalism implies cultural and organizational changes. While the individual responsibility of success conveys a gender-neutral image, the transition from the public sector to the male-dominated private sector is apparent and is reshaping women's participation in the labor force (Homburg et al., 2007). The pursuit of principles of individualization, decentralization and the free market led to varying implementation of private providers, budgeting, and performance benchmarking. Due to the similarity within the implementations, but also the impact on budget deficits, public distrust, and administrative changes, these reforms have been referred to as NPM. However, implementations and their incentives may differ between countries (Homburg et al., 2007).

4.2 Characteristics of New Public Management

NPM as a global reform emerged from the features of public administration, which was intended to compensate the underperformance and fiscal deficits. The NPM, defined by Cristopher Hood (1991), with a market-like structure was intended to remedy the deficit and at the same time improve the quality of public service (Homburg et al., 2007). The global trend is reflected above all in the western industrialized nations and developed countries in Asia and Africa, and receives a lot of support. In Great Britain, NPM was radically applied under Thatcher, while the USA under Reagan was likewise considered to be the first countries to adopt this idea (Auth, 2012). As a result of this popularity, NPM is being applied in all public services, leading to changes from the level of governmental organization to local government and health care systems (Diefenbach, 2009). Despite the heterogeneous management and market-based approaches and principles of NPM, the introduction of NPM has taken place differently in each country, depending on structural characteristics and traditions (Homburg et al., 2007). Due to the high presence within the scientific context and accompanying high

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number of publications, combined with the varying implementations of NPM structures in different countries, it is thus difficult to define NPM accurately, making it more elusive to grasp (Diefenbach, 2009). According to den Heyer (2011), NPM is subject to the five theoretical concepts: public choice theory, principal agent theory, transaction cost theory, technical rational theory and institutional theory. Within the scope of this thesis, the individual theories cannot be addressed in more detail. Nevertheless, for NPM, the public choice and principal agent theories are the most influential (den Heyer, 2011).

According to Hood (1991; 1995), the elements of the NPM can vary between the countries but can be summed up into the following seven core elements: decentralization,

privatization, private sector management, cost reduction, management, performance standards and output controls.

The decentralization involves the breaking up and delegating large, hierarchical structures and transfer them into smaller units in order to be located as close as possible to the point of action and to improve the accountabilities and cost management. By establishing smaller decentralized units, the services offered should be more customized and effective, thus preventing unnecessary expenditures (Hood, 1995). This disaggregation of institutional structures is thus intended to change control patterns and create a flatter hierarchy (Dunleavy et al., 2006, p. 470).

Increasing privatization and more competition in general (where applicable, quasi-markets) will be pursued. The competition is intended to raise qualitative standards, make organizations more effective and to decrease their expenditures. A lot of emphasis is put on contracts, which define the services to be provided and which need to be measurable in order to determine the outcomes. This reinforces the contractual basis with the service recipients and is intended to illustrate the relationship of service provider to customers and the free market (Hood, 1995).

In the course of privatization, private service management is likewise to be transferred to the public sector. Relating to the individual accountability, clear common objectives are to be agreed in short-term employments. Based on specific tools and techniques of the private sector, a higher flexibility and reward system should be adopted (Hood, 1995).

Cost reduction is an important element of NPMs and is particularly focused on making

processes more efficient. The aim is to save costs directly and thus standardize work with a minimized budget, even if this implies poorer working and employment conditions. The guiding principle “Do more with less” reflects the increased efficiency in delivering more services with fewer resources, aiming to reduce expenses (Hood, 1995, p. 96).

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Considering the management, a hands-on management style is demanded, with clear guidelines and lines of responsibility, such as policies and procedures. With the higher accountability, the tasks are to be clearly allocated (Hood, 1995). Thereby, success and failure are measured in effectiveness on the basis of performance with focus on financial incentives, so called “incentivization” (Dunleavy et al., 2006, p. 470).

In order to make operations more efficient, objectives and goals must be clearly defined and made quantitatively verifiable. These performance standards and accompanying implementation of performance indicators is intended to ensure accountability and to target expenditures (Hood, 1995).

Given the output controls, instead of focusing on input and procedure, the NPM focuses on outcomes and associated results, which is accompanied by a reward system based on the performance and distribution of resources (Hood, 1995).

Thereby, outsourcing is equally applied as a tool to minimize costs and improve quality simultaneously (Belcourt, 2006). In terms of the gender perspective, based on the gender-neutral self-responsibility of neoliberalism, the NPM is intended to improve opportunities for women in the context of social work and to enable them to achieve promotion from low-level positions (Barry et al., 2007). Despite the positive aspects of NPM advocated by neoliberalists, the implementation of management content from the private sector into the public sector involves challenges. The two sectors are quite different in their conception as well as very complex, which makes the transfer of economic principles contradictory to some of the contents of the public sector (den Heyer, 2011). At the same time, the implementation of NPM principles is so widely established, yet so differently implemented as well as universal, that it is no longer possible to discern a precise approach. Thus, NPM can be recognized in different ways and can be distinguished by a variety of characteristics and therefore can be identified only in certain areas, such as the organizational culture, performance management or the implementation of control mechanisms. Among other things, the increasing complexity due to NPM structures is addressed, which, however, is not positively related to social problems and thus causes decreasing trust in the state and its bureaucracy (Dunleavy et al., 2006).

With the article "New Public Management Is Dead—Long Live Digital-Era Governance" by Dunleavy et al. (2006), the debate and the paradigm shift become apparent, but also points out the alternative of the new digital-era governance (DEG), which is characterized by the three core contents of “reintegration, digitization changes and needs-based holism” (Dunleavy et al., 2006, p. 480). In this context, the emphasis lies on changing the corporate structures that have been created in order to make the services provided by the welfare state more accessible to the population again. The holistic approach of simplifying the relationship between the recipient

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and the provider of services and thus being able to respond better to social problems is closely linked in this respect. In order to meet the organizational demands, digital operations should additionally no longer only serve as a complementary element, but rather act primarily (Dunleavy et al., 2006).

4.3 New Public Management in elderly care

Due to the high future demands on the care sector due to demographic change and already critical conditions in the care of older adults, the field of elderly care presented itself as an area with particularly high potential to increase effectiveness. Thus, elderly care is one of the areas with the greatest impact from NPM. Due to the substantial transformations within the organization, both the management, the profession and the identity of care changed (Kamp & Hvid, 2012). A critical appraisal is given to the question of how the economic logic of neoliberalism and NPM should cope with the lack of, but necessary, predictability of needs and resources. This incompatibility would lead to a deficit of resources and thus to a lack of care, as well as to a negative impact on the health of the staff (Hoppania & Vaittinen, 2015).

4.3.1 New Public Management in Germany

In the 1990s, the NPM debate reached Germany and likewise implied the reorganization of state, municipal responsibilities and tasks (Naschold & Bogumil, 2013). The idea of NPM was strongly pursued and already in 1995, 98% of major local governments attempted to implement elements of NPM. Despite the introduction of the administrative reform as an institutionalized task of local governments, the results were rather modest. The reform was integrated rather superficially, and despite the stronger focus on cost efficiency, difficulties remained. Particularly in the areas where outcomes are difficult to measure, implementation was limited and led to criticism regarding the resulting tight budgeting and insecure labor relations (Elsenhans et al., 2005).

In addition to the increasing burden of debt due to high public expenditures, the strategy deficit in the actions of municipal authorities was also pointed out. Thus, the NPM, referred to in the international context, was introduced in Germany as the “Neues Steuerungsmodell/New Steering Model” (NSM) and aimed likewise towards increasing efficiency and introducing a greater customer emphasis. In addition to enhancing customer focus, there were three other core contents of the NSM. On one hand, the quality improvement and activation of the structures through competition and on the other hand the output control, which links the reorganization in products to the accounting system. The fourth element was the goal of establishing a corporate-like structure and thus decentralizing management and

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organizations. However, it should be emphasized that the NSM was a concept of the “Kommunale Gemeinschaftsstelle für Verwaltungsmanagement” KGSt association and therefore non-binding and a voluntary offer to the municipalities to implement elements of administrative modernization (Weiß, 2013).

In contrast, with the introduction of the LTCI in 1995/1996, the focus shifted increasingly to the logic of the market, with a stronger focus on the consumer role, as well as on increasing efficiency. Thus, the economic efficiency of the services is clearly formulated in § 29 SGB XI (1994). In the course of the rationalization of services, they were thus standardized in units of time and assigned corresponding compensation rates. However, the standardization in the ambulatory care results in a discrepancy with the social context of the care. Individual needs cannot be externally timed and do not include space for, for example, social interactions such as conversations. Thus, the standardization of care can hardly meet social care requirements and is therefore considered critical in terms of quality measurement and definition of good care (Pfau-Effinger et al., 2008). The study by Schwaller (2013) and the observation and interviewing of eleven nurses in home care demonstrate the tendency that operational efficiency and profitability criteria are gaining in importance, while fundamental values of care are being questioned.

The introduction of LTCI, and thus the initiation of de-municipalization, was intended both to relieve the burden on social welfare institutions and also to improve the infrastructure of care. This included the authorization of private providers and thus the introduction of competition and the strengthening of home care. As a result, private providers already dominate home care with a share of 60% (Auth, 2012).

4.3.2 New Public Management in Sweden

In contrast to the ideal of the social-democratic welfare state with universal and generous benefits, from the 1970s onwards there was increased doubt about the public sector. The public bureaucracy was criticized for too high expenditures and too much autonomy, leading the way for administrative reform to reshape the concept of the entire organization. Among these, the budget deficit was one of Sweden's biggest problems (Premfors, 1998). Even though, according to Hood (1995), Sweden shows the most controversy regarding NPM, it has the necessary structures to implement the administrative models. Thus, the reform movement and the ideas of NPM were strongly implemented in Sweden in comparison to other countries (Solli & Czarniawska, 2014). In this way, Sweden already implemented outsourcing and privatization in 1992 (Kamp & Hvid, 2012). Due to the different implementations and variations within the process, many so-called hybrid forms can be found in Sweden, where private actors are financed by state funds, as well as state institutions are funded with fees from

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private households (Solli & Czarniawska, 2014). Although welfare services are still mostly state-funded, the delivery of services has been progressively transferred to private providers/quasi-markets (Storbjörk & Stenius, 2019). Based on the study by Stolt & Winblad (2009), it could be identified that the degree of privatization varies geographically and between municipalities and focused on highly populated areas.

The privatization of services was known from the field of addiction, but already encountered criticism against the principle of universalism of the welfare state (Storbjörk & Stenius, 2019). However, increasing privatization in care in Sweden prevailed and against the of NPM intended cost reductions through privatization, the opposite could be identified and even conclusions on the quality of care were rather negative (Storbjörk & Stenius, 2019). According to Storbjörk & Stenius (2019, p. 778) the expenditures of private providers increased by 57%, while public providers increased by only 14% in the same period from 2009 to 2013. Another study by Stenius and Storbjörk (2021), including experiences of 29 professionals within the substance use treatment systems, does not identify greater resource efficiency through NPM measures. However, it describes a devaluing development of social work practice with regard to documentation and standardization.

In the course of the Ädel-reform in 1992, the health care system was restructured and thus the responsibility for care provision was transferred to the municipalities. In the course of this decentralization process, the previously mentioned private operators were authorized in order to increase the quality of care through competition and to enable freedom of choice for older adults (Auth, 2012). Due to lack of recession-related financial resources and the increasing demand for care, decentralization reduced the burden on hospitals and resulted in de-medicalization. As a result, benefits have been targeted intensively at older adults who are in need of severe care, thus weakening the entitlement to universally available benefits (Auth, 2012). The percentage of recipients of services from the age of 65 or older decreased from 17% in 1975 to 8% in 2000 (Johansson et al., 2003), whereas, according to Socialstyrelsen (2021), the share of people over 65 years of age has decreased from 8,0% in 2014 to 7,1% in 2020 in the area of residential care under SoL and from 4,3% to 3,7% in the case of home care. Along with the emphasis on those in severe need of care, deinstitutionalization is also to be introduced. The intention is to transfer a certain degree of responsibility for care to the family. Thus, the trend in Swedish care provision is toward refamiliarization and privatization (Auth, 2012). Due to the decline in state services, the share of family care increases, which is mostly carried out by women and are therefore more influenced by care responsibilities. According to Jolanki et al. (2014), however, the legal basis and measures to support and compensate family care for relatives providing care are inadequately developed and require action. The 33% increase in homecare recipients and the 24% decrease in residential beds for the older adults

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highlights the deinstitutionalization process (Ulmanen & Szebehely, 2015). In this context, the demand on those in need of care to buy services privately as a result of the reduction in public benefits is critical. After all, not everyone's family can take over the care or the necessary financial resources are available, which promotes social injustice (Szebehely & Ulmanen, 2012). Furthermore, the share of family caregiving is not evenly distributed in society, but is more prevalent among older adults with lower education in Sweden (Szebehely & Meagher, 2018). In addition, the responsibility of caring for a relative, passed on to the family, is particularly on the cost of women's labor participation and thus also increasingly promotes gender inequalities (Szebehely & Ulmanen, 2012). Consequently, only the economically better off benefit from privatization and the introduction of choice, as they can purchase or supplement services accordingly. While older adults with fewer resources are dependent on family care and thus tend to be taken care of by unqualified relatives, which may negatively affect both relatives and those in need of care (Szebehely & Meagher, 2018; Szebehely & Trydegård, 2012). Due to the marketization of care and the introduction of economic instruments, the assessments have also been standardized and the services limited (Olaison, 2017).

4.4 Effects on Social Work

In relation to other European studies in various areas of social welfare, the study by Alonso et al. (2014) can be cited with regard to the efficiency maximization intended through NPM principles. In this study, the increase in efficiency in 25 hospitals through the introduction of new management tools was investigated and no differences in efficiency could be identified between traditional and NPM-modified hospitals. In addition, there was no evidence that public institutions are more inefficient than private ones. Through this example, similar developments and effects can be observed also from other areas than social work. According to the review of NPM literature in Central Europe by Dan & Pollitt (2015), it becomes apparent that many studies did not consider the reforms to be successful. However, it could be identified that some NPM measures, such as performance management, quality enhancement and the establishment of agencies, have led to some improvement. Thus, an adequate NPM measure, in the specific context, can lead to improvements in service provision and organizations. However, the principles of NPM and those of social work can contradict and lead to tensions, as in Höjer & Forkby's (2011) study in the area of child protection.

When implementing economic and managerial instruments, however, they encounter difficulties in the care sector and lead to conflicts in practice. The intention to make better use of resources and improve quality is rather the opposite. More resources have to be used for

&quot;Only seeing the numbers and forgetting the people behind&quot; - The influence of New Public Management on elderly care : A country comparison between Germany and Sweden