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Healthcare and social care for older adults to enhance crisis preparedness 

Ann Liljas and Bo Burström 

In the Nordic region, the proportion of older adults in the population is growing rapidly. The COVID-19 pandemic exposed long-known shortcomings in healthcare and social care systems for older adults in need of complex care, not least in Sweden. The social care sector for older adults was unprepared and ill-equipped when the pandemic struck. The shortcomings in socialcare for older adults were due to, among other things, a lack of resources, fragmented organisation and insufficient staffing. Mortality affected mainly older adults and frail indivi­duals, especially in Sweden but also in other Nordic countries. The majority of healthcare and social care staff are women, but fewer and fewer are choosing to work in this sector. How can healthcare and social care be designed sustainably, both now and in the future, to also make the system more resilient to future crises?

Why focus on healthcare and social care for older adults?

The proportion of older adults in the population is increasing rapidly in the Nordic region and the rest of the world. In Sweden, Statistics Sweden has predicted that the proportion of people aged 80 years and older will increase by 60 per cent between 2018 and 2030 (Statistiska Centralbyrån, 2025). The increase is also expected to continue in the future. Although life expectancy is increasing over time (Enroth et al., 2022), social disparities are also increasing, not least in terms of income (Nordregio, 2024). The proportion of people aged 80 years and older in the population is sometimes seen as an indicator of the need for healthcare and medical care, as the incidence of illness increases with age. More people will have multiple illnesses simultaneously (multimorbidity) and thus need good, local care, delivered in collaboration between healthcare and social care services. This pattern is evident throughout the Nordic region. The text in this essay is based on research on Sweden, but given the many similarities between the Nordic countries, it can hopefully contribute to learning for the entire region.
The COVID-19 pandemic exposed long-standing shortcomings in the healthcare and social care systems for older adults in need of complex care. According to the Swedish Coronavirus Commission (SOU 2020:80), the social care sector for older adults was unprepared and ill-equipped when the pandemic hit, despite the presence of structural shortcomings being known in advance, and the then government, as well as previous governments, should have taken action to address this. The shortcomings in the preparedness of social care for older adults were due to, among other things, fragmented organisation, a lack of staff, low competence, and unreasonable working conditions, an inadequate regulatory framework, obstacles for municipalities to employ doctors and gain access to medical equipment, and late and sometimes poor decision-making and ineffective measures. The Coronavirus Commission also sharply criticised the late and inadequate measures taken to prevent the spread of infection early in the pandemic, which increased the general spread of infection and thus also the risk of infection among older adults. Furthermore, the government should have been clearer in its leadership in terms of managing the crisis (SOU 2022:10).
This pandemic, which hit older adults particularly hard, is perhaps the clearest example of the need for resilience in healthcare and social care systems. In Sweden, as in the other Nordic countries, the majority of those who died between 2020 and 2022 were aged 70 years or older (Socialstyrelsen, 2024a). Most of them (72 per cent) lived in care homes for older adults (long-term accommodation, living in their own flat, staffed around the clock). The proportion of the population that died from COVID-19 was significantly higher in Sweden than in the other Nordic countries. However, our study on excess mortality paints a more complex picture. To calculate excess mortality, the number of deaths for a specific period is compared with a previous period. In Sweden, excess mortality was elevated in 2020. However, the results showed that excess mortality during 2020-2022 was comparable to Denmark and Norway, while Finland had twice the excess mortality of Sweden (Burström et al., 2024).
The fragmented organisation of social care for older adults cited by the Coronavirus Commission refers to the division of responsibilities. In Sweden, social care for older adults is a municipal responsibility, while medical and nursing care is a regional responsibility. Municipalities are also responsible for home help and can employ nurses for this purpose. Medical involvement requires an agreement with the region. The fact that older adults receiving home help and living in care homes were at highest risk of dying reflects the vulnerability of these individuals but also suggests that there is potential for the system to be improved at the strategic level (e.g. improved facilities), tactical level (staff) and operational level (e.g. cohort care and personal protective equipment). In turn, there may be significant potential for cross-organisational learning, both nationally and through the exchange of knowledge and information with other Nordic countries, which have similarly designed healthcare and social care systems albeit with slight variations (Szebehely, 2020). The Swedish COVID-19 Committee’s interim report clearly described the shortcomings of the Swedish healthcare and social care system for older adults and the measures that would be needed. More extensive and effective collaboration, as well as greater involvement of doctors in municipal healthcare and medical care, is needed, but no comprehensive measures have yet been taken. According to the final report from the inquiry God och nära vård (High-quality and local healthcare; SOU 2019:29), a greater proportion of care should be provided locally as primary care (general medical care through health centres), which is expected to cover the majority of care needs (Myndigheten för vård- och omsorgsanalys, 2025). Similar trends can be seen across the Nordic countries, which are all experiencing challenges in recruiting staff (Larsen et al., 2020). Healthcare and social care is a female-dominated sector, both among professional staff and those who provide care within the family. Particularly in social care, not least home help (care provided in the home), many women are underpaid compared to male-dominated sectors such as construction (Nordic Council of Ministers, 2019). There are also gender aspects with regard to care recipients within healthcare and social care for older adults: a large proportion of vulnerable older adults who receive healthcare and social care are women. Additionally, there are also socio-economic differences in health and in the need for healthcare and social care (Jämställdhetsmyndigheten, 2022).
With a rapidly ageing population and the experience of a widespread crisis that primarily affected older adults, there is reason to study the concept of resilience in relation to healthcare and social care for older adults. When discussing the concept of resilience in this text, we are referring to the need for the healthcare and social care system, rather than older individuals, to develop the resilience to cope with crises such as a pandemic. Furthermore, we see resilience as an ongoing process rather than a one-off phenomenon. Through restoring, maintaining and improving, the system can be developed to function in the long term and thus be sustainable (Helmen Borge, 2005). In terms of restoring, we are referring to a short-term process by which the system returns to normal after a crisis. In the meantime, its function must be maintained to allow for improvements to be made, for example, after a crisis. By asking questions and exploring them, we can gain insight into how resilience can be expressed and develop guidance on how healthcare and social care systems could be designed (Helmen Borge, 2005).  

What is the current situation regarding healthcare and social care for older adults? 

The Nordic countries have similar systems in terms of healthcare and social care for older adults, but there are some variations in the design and delivery of services (Vabø & Szebehely, 2012). Common to all is the demographic challenge of an increasing proportion of older adults and difficulties recruiting staff. The coverage rate, i.e. the proportion of older adults covered by comprehensive social care for older adults (those receiving home help or in care homes), is highest in Denmark, while Norway has the highest proportion of older adults in care homes and Sweden has the highest proportion of older adults receiving home help. Finland has the lowest overall coverage rate but also has a higher proportion of older adults receiving formal (paid) social care from family members or other close friends or relatives. Informal care is common in all Nordic countries (Myndigheten för vård- och omsorgsanalys, 2021).
The Nordic countries invest a large proportion of their GDP into social care for older adults. In 2018, the proportion was 2.4 per cent in Sweden, 2.3 per cent in Norway, 2.0 per cent in Denmark and 1.7 per cent in Finland (Myndigheten för vård- och omsorgsanalys, 2021). Previous reports have shown that Iceland has a lower expenditure than the other Nordic countries (0.5 per cent in 2012 compared to 2.3 per cent in Sweden in the same year; Nordic Social Statistical Committee, 2013). In all five countries, social care is provided by a mix of public and private providers. In Sweden, the proportion of profit-making providers is highest, while other countries have a larger proportion of non-profit providers. In Denmark and Norway, municipalities may be exempt from competition with for-profit operators and award contracts directly to non-profit organisations. There are shortcomings in the coordination of medical and nursing services in all Nordic countries, despite the slight organisational variances between the countries (Larsen et al., 2020). In Iceland, the state and municipalities collaborate on the provision of social care for older adults. In Finland and Norway, municipalities are responsible for both social care for older adults and primary care, which can facilitate collaboration. In Sweden, services are divided between municipalities and regions, which can complicate delivery of medical care and social care for older adults (Myndigheten för vård- och omsorgsanalys, 2021).
Despite the ongoing increase in the proportion and number of older adults among the Swedish population, the number of people in care homes decreased from 82,626 in 2017 to 77,173 in 2021 (Socialstyrelsen, 2023). However, the cost per person per year increased by approximately SEK 100,000 during the same period, to SEK 1,020,427. The total costs for municipalities for care homes, home help and home nursing care increased by 3.9 per cent between 2017 and 2021, mainly driven by increased costs for home help (9 per cent). However, care homes account for the largest share (57 per cent) of costs. In 2021, a total of 227,400 people aged 65 years and older received municipally funded home nursing care. Approximately half of these also received home help services. More than half of those who received home nursing care were aged 80 years and older, and 60 per cent also received home help services.
It has long been known that there are problems with understaffing and recruitment within primary care, not only in Sweden but in several Nordic countries (Nordic Council of Ministers, 2014). Similarly, in social care, there is a growing need and uncertainty with regard to future recruitment opportunities, which will be necessary to meet the growing needs of an ageing population. In Sweden, an additional 59,000 people will need to be employed in social care for older adults by 2031 to meet increased need. Factoring in retirement, the total recruitment need will be 110,000 people. Of the 191,000 people employed in social care for older adults in 2022, 45 per cent were nursing assistants and 24 per cent were care assistants. Among care assistants, 60 per cent had fixed-term contracts, while among nursing assistants the figure was 16 per cent. Almost half of both occupational categories worked part-time (Socialstyrelsen, 2023). It is therefore worrying that the number of nurses in social care for older adults is declining slightly, as is the proportion of specialist doctors in geriatrics. During the pandemic (2020), inspections were carried out at 98 care home facilities in Sweden, which found that one-fifth of residents had not received an individual medical assessment. A follow-up survey in 2022 showed that, compared to 2021, 60 per cent of municipalities reported that access to doctors was unchanged, while 16 per cent reported that access had declined; only 10 per cent reported that access to doctors had increased. Among municipalities that employed specialist nurses, 81 per cent reported shortages in the availability of such staff. The shortages were said to be due to competition from other employers and a lack of specialist nurses.
In Sweden, municipalities have different user fees for social care. Most municipalities charge the maximum fee for round-the-clock care (SEK 2,139/month), but there are large variations in costs of food and home help hours (SEK 70-488/hour). Most municipalities charge SEK 200-400 per hour. High costs in a municipality affect access to home help for low-income earners (Socialstyrelsen, 2023). National insurance contributions in the Nordic countries vary between 5 and 8 per cent across Sweden, Norway and Denmark, while contributions are about 17 per cent in Finland (Myndigheten för vård- och omsorgsanalys, 2021). In summary, it can be said that healthcare and social care for older adults are facing major challenges in all five countries, both due to the increasing proportion of older adults and difficulties recruiting staff.

Women sustain healthcare and social care for older adults

Women outnumber men in the health and social care employment sector. The most common occupation among women in Sweden in 2023 was nursing assistant, a profession in which 112,100 women and 15,900 men were employed (Kindblom & Westholm, 2025). Female-dominated professions are characterised, on average, by lower pay and poorer working conditions compared to male-dominated professions. The shortage of staff in social care for older adults is partly due to poorer employment conditions, working environment and pay.
Gender pay gaps reflect levels of disposable income among women, which are approximately 20 per cent lower than for men (Jämställdhetsmyndigheten, 2025). Many people working in social care for older adults are foreign born, which can mean they face language barriers and have limited insight into their rights. Women also often work part-time or in hourly positions, allowing employers to cover staffing needs when necessary. However, this creates uncertainty and insecurity for employees over their incomes and livelihoods, as well as that of any family members. For many, accepting shifts at short notice is therefore necessary to support themselves and continue to be seen as an attractive employee.
During the COVID-19 pandemic, hourly staff were brought in to a much greater extent than usual to cover sick leave among regular staff. However, high staff turnover also increased the risk of infection. In addition, some temporary workers did not turn down shifts despite exhibiting symptoms of infection due to fear of lost income and being looked over for work in the future. This exposed a social problem that needs to be addressed before the next pandemic or other crisis hits: workers must be guaranteed income security during times of crisis and that they will still be seen as an attractive employee on the labour market beyond the crisis.
The Swedish trade union Kommunal represents a large proportion of workers in social care for older adults. In their 2022 survey, only 46 per cent of members within the field stated that they wanted to continue working in social care for older adults over the next three years. When the same survey was conducted ten years earlier, that figure was 76 per cent. The main reasons for not wanting to continue were related to the poor working environment, not being able to work until retirement, pensions being too low and salaries being too low (Bucht, 2023). The working environment in healthcare is too often characterised by high workloads combined with insufficient staffing, a lack of care places and long waiting times. These factors are also examples of causes of moral distress among healthcare staff (Brune et al., 2024). Moral distress occurs when a person feels inadequate in doing what is considered ethically correct, which not only negatively affects staff but can also jeopardise patient safety (Canadian Medical Association, 2020). Such situations occur frequently among healthcare and social care staff and are largely a result of resource shortages.
The shortcomings and challenges highlighted above have been known for a long time but need to be addressed as soon as possible. It also shows that resilience within the healthcare and social care system with regard to staff must first be restored in order to be maintained and further improved in the future. This is critical for the healthcare and social care system but also central from a gender perspective as the majority of staff are women.

Reforms and investigations concerning healthcare and social care for older adults in Sweden

How is the issue of healthcare and social care for older adults handled politically? What reforms and changes have been proposed to improve the situation? What effect have these had? Below are some current examples from Sweden.

The Act of Systems of Choice

A large proportion of medical and nursing care for older adults with complex care and social care needs is expected to be provided through primary care, while social care is expected to be provided by municipal services. The Act on Systems of Choice (LOV) (SFS 2008:962) came into force on 1 January 2009 and applies to municipalities and regions when they establish freedom of choice systems for healthcare and social services. While it is voluntary for municipalities to introduce freedom of choice systems, it is mandatory within regional primary care. The reform thus ensures freedom of establishment for activities that meet basic requirements, with public funding from the municipality and region respectively.
Just over half of Sweden’s municipalities have introduced LOV (SFS 2008:962) in social care for older adults, more so in large cities in the south and less so in the north and in sparsely populated municipalities. Around 20 per cent of all care homes for older adults are privately run and 24 per cent of home help hours are provided by private operators (Vårdföretagarna, 2022).

Primary Health Care Choice Reform

The Primary Health Care Choice Reform was implemented nationally in 2010 and resulted in an increase of approximately 20 per cent in new health centres, the majority of which are profit-driven limited companies. Most new establishments were located in large cities, with fewer in rural areas and on the outskirts of cities. The proportion of private healthcare providers is highest in the Region Stockholm (69 per cent of all healthcare centres) and lowest in the Västerbotten Region (13 per cent). Individuals/​patients can register at the healthcare centre of their choice, and the cost of their care is paid by the region.
The Primary Health Care Choice Reform has been criticised for depriving regions of their ability to manage establishments according to need and for the increase in primary care visits largely among people with minor needs (Burström et al., 2017; Riksrevisionen, 2014).
In addition, a government inquiry (SOU 2016:2) found that the Primary Health Care Choice Reform has made it more difficult to care for older adults with complex care needs, as the reform has led to a lack of coordination and collaboration. In view of this, the report proposed that those in this group be exempt from the Primary Health Care Choice Reform and given a special track within primary care. However, this has never been discussed further or tested. 

High-quality and local healthcare

Another report, God och nära vård (High-quality and local healthcare; SOU 2019:29), proposes that primary care should be strengthened and form the basis of the medical and nursing care system and a hub for the care of older adults with complex needs, alongside municipal social care. The National Board of Health and Welfare’s follow-up of God och nära vård (High-quality and local healthcare; 2023) reported a slight increase in collaboration between responsible authorities but a decline in opportunities to see a doctor at care homes for older adults when needed and no increase in the proportion of patients with a regular doctor, healthcare contact or social care contact. In the spring of 2025, the Swedish Agency for Health and Care Services Analysis presented a final report on the transition to high-quality and local healthcare, in which they drew similar conclusions. They further noted that none of the goals of the transition had been achieved, probably because operations have not received improved resources (Myndigheten för vård- och omsorgsanalys, 2025). This is remarkable, as the report by the National Board of Health and Welfare already stated that financial challenges across regions and municipalities could affect the transition work (Socialstyrelsen, 2024b).

Investigation into an act on social care for older adults

During the pandemic, possible changes to the Social Services Act were discussed, including, for example, on care homes for older adults and a so-called social care for older adults act with possible changes to expand medical expertise in care homes. Work on updating the Social Services Act is currently underway. A report on the introduction of an act on social care for older adults was presented in the summer of 2022, focusing on increased quality and equality in healthcare and social care for older adults (SOU 2022:41). The report contained proposals on how medical and nursing care legislation could be strengthened to improve the quality and availability of healthcare and social care for older adults. The proposal covered both municipalities that provide social care and regions that provide healthcare. It also included measures on health promotion and disease prevention, as well as person-centred approaches. However, the government chose not to proceed with the introduction of an act on social care for older adults, which brought the undertaking to a halt.

Investigation into strengthening medical expertise in municipal medical and nursing care

A commission also presented a report on strengthening medical expertise in municipal medical and nursing care (SOU 2024:72). The report points out that municipal medical and nursing care will become increasingly important in the transition to high-quality and local care. The report proposes, among other things, that municipalities should be able to employ doctors, that municipalities should have a medical management function and that regions should have a function that acts as a counterpart to municipal healthcare and medical care, which can be important, not least in the event of extraordinary events or increased preparedness. It also proposes that the state should allocate funds for the further training of nurses in municipal medical and nursing care. However, the proposal for municipally employed doctors has been criticised by both the Swedish Medical Association and the Swedish Medical Society (Torkelsson, 2025).
In summary: A review of reforms and investigations shows that not much has changed that could improve healthcare and social care for older adults. Older adults with complex needs did not benefit from the Primary Health Care Choice Reform – if anything, it increased the fragmentation of healthcare and social care. A proposal to exempt this group and create a special track in primary care did not go ahead. In care for older adults, the number of private providers has increased, but a large proportion of those in need of care lack the resources and cognitive ability to make choices. Freedom of choice is also geographically limited to large cities. The proposal for an act on social care for older adults did not go ahead, nor did the proposal that municipalities should be able to employ doctors to provide healthcare and social care for older adults. The report on a transition to high-quality and local healthcare is therefore one of the few conceivable ways forward and contains many proposed improvements, but the lack of financial resources and recruitment difficulties across regions and municipalities make implementation difficult.

What can be done to improve healthcare and social care for older people?

Beyond additional resources for healthcare and social care, there is a need to further develop existing working methods and establish new ones. In Sweden, the COVID-19 pandemic highlighted the importance of nurse practitioners, who collaborate with, for example, care homes for older adults. Municipal nurse practitioners were responsible for ensuring that healthcare was administered safely and correctly, which in practice could mean training staff in how to use personal protective equipment correctly and reduce the spread of infection through proper hygiene. Research has shown that nurse practitioners also played a central role in clarifying and communicating the constantly changing guidelines from the health and medical authorities to, among others, care homes for older adults. In municipalities where nurse practitioners took on such a role, the burden on staff at care homes for older adults was eased in terms of managing and communicating new guidelines and recommendations to staff (Liljas et al., 2024). In preparing for future crises and pandemics, the experiences of decisive and significant efforts by nurse practitioners during COVID-19 should therefore be taken into account. The role and importance of nurse practitioners in daily operations should also be prioritised to establish routines that will form a basis for future crises.
Another important lesson from the COVID-19 pandemic is that communication from authorities must be clear and consistent. During the pandemic, too many different guidelines were issued, which healthcare and social care staff found confusing and contradictory, causing further uncertainty among staff (Agerholm et al., 2023; Liljas et al., 2024). This is unfortunate in several ways, as international research from the 2009 influenza epidemic showed that information should be communicated from a single credible source, such as a government agency (Staes et al., 2011). The same study also showed that, given the vast amounts of information available, information that is potentially new to people should be clearly indicated. This guidance was available prior to the COVID-19 pandemic, but was not taken into account. This shows that the dissemination of research must become more effective.
The World Health Organisation (WHO) advocates for patient-centred integrated healthcare and social care, arguing that such an approach offers significant opportunities to meet the needs of an ageing population. However, a survey within primary care in the Nordic countries showed that integrated healthcare is very limited: no Nordic country has introduced nationally integrated healthcare. The initiatives that do exist consist of local projects in a few municipalities or regions (Larsen et al., 2020). It is clear that closer cooperation is needed between regional medical and nursing care and municipal medical and nursing care and social care. Care for older adults must become a more attractive field of work, and staff need to be the focus of initiatives aimed at improving training, employment conditions, working environments and pay.
Although the challenges described above appear to be substantial, there are examples of promising local initiatives throughout the Nordic region. It is important to follow up and learn from a variety of approaches. One Swedish example is the municipality of Norrtälje, which has an older population than the rest of the Region Stockholm. The need for healthcare and social care in this area is therefore greater than for other population groups in the county. In the early 2000s, the emergency hospital in Norrtälje was threatened with closure but was eventually converted into a local hospital through in-depth collaboration between the then county council and the municipality, which resulted in a joint organisation (Tiohundra) sustained through co-financing. This integrated healthcare and social care system has been widely praised by both patients and staff, who feel that communication between units and actors is facilitated by having a joint organisation, which in turn has resulted in both a seamless healthcare and social care chain and a good working environment. A study of COVID-19 mortality among people aged 70 years and older in the Region Stockholm showed a lower mortality rate in Norrtälje than in other municipalities (Doheny et al., 2024), which may be partly due to the closer cooperation and communication (Nordic Welfare Centre, n.d.). The Region Stockholm budget for 2025 explicitly states that an investigation will be conducted into how the Norrtälje model can be spread to other operations within the region.
In Sweden, other local models with increased cooperation between social care, primary care, home nursing care and hospitals have also been studied, including in Borgholm in Region Kalmar County, Region Västmanland and Storuman in Region Västerbotten (Ström, 2018, 2023; Castilla, 2025). These models all ensure close communication between all actors involved in care for older adults and that the majority of care is provided in the home.
Another example can be found in Norway, where a model for integrated care aimed at frail older adults has been praised for focusing resources on older adults who would otherwise be at risk of multiple hospital admissions. The model is based on applying a holistic approach to patient needs. A geriatrician, family doctor and nurses from both the hospital and municipality meet with the patient and develop a care plan focused on what is important for the patient to be able to cope with in everyday life. Goals are followed up every six months to enable older adults to continue living at home. The model was launched in the early 2020s and has already spread to several municipalities in southern Norway. The model is an example of how older adults can be empowered to live independently in a way that strengthens society (Hamre, 2023).

Final reflections

In its report, the Swedish Agency for Health and Care Services Analysis states that the failure to achieve the goal of high-quality and local care is due to, among other things, a lack of financial and human resources. Strengthening primary care is crucial, yet not currently being given sufficient priority. The report also recommends greater government control over the transition to local healthcare (Myndigheten för vård- och omsorgsanalys, 2025). Given the existing difficulties in healthcare and social care for older adults, and based on the current demographic challenge of the rapidly increasing proportion and number of older adults in the population, extensive resources and measures are required. A clear vision and plan are needed, both from the state and in regions and municipalities in Sweden. Increased exchange of experience and learning between the Nordic countries could enable new solutions, as many of these challenges are shared.
Greater collaboration is needed between social care and healthcare and medical care. A number of different approaches are likely to be needed, adapted to local conditions. To successfully care for older adults, the status, working conditions and working environment of those who work in healthcare and social care, mainly women, need to be improved. Furthermore, the proposals for reform that have been developed should be tested, followed up and evaluated scientifically. The experiences gained during the pandemic should be used to strengthen systems in preparation for future crises. By learning from the differences and initiatives in the Nordic countries, in terms of both structure and approach, the care of older adults can be improved.       
  • Resources for healthcare and social care systems for older adults must be strengthened. Since multiple illnesses often require both healthcare and social care, it is clear that closer collaboration is needed between regional medical and nursing services on the one hand, and municipal medical and nursing and social care services on the other.
  • Clear visions and plans are needed at multiple levels for the implementation of proposed reforms. The implementation of proposed reforms should be monitored and evaluated scientifically. 
  • Social care for older adults must become a more attractive field of work, and staff need to be the focus of initiatives aimed at improving training, employment conditions, working environments and salaries.
  • Greater exchange of experience and learning between the Nordic countries could enable new solutions, as the problems and challenges faced are in many respects common in these countries. Experiences from the pandemic should be utilised to avoid extra work and prepare and strengthen systems for future crises.  

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