30 Jan 2017

Overview: long-term care in Europe

The ageing population in Europe

Across the EU, 95m persons are aged 65 and over, equating to 18.5% of the total population. This has radically changed the population structure of Europe since 1950.

Approximately 45% of individuals aged 65+ have a disability, and between 20% and 33% of individuals aged 65 and over require care/support, depending on how care is defined. Over a quarter of the total older population are aged 80+, and around half of all LTC users are aged 80 and over.

Organisation of LTC in Europe

In light of the rapid population ageing, LTC policies have undergone significant reform in most countries over the last two decades.
Until the late 1990s, Northern and Western European countries were largely characterised by high levels of state support and public provision for older persons in need of care, while Southern and peripheral countries were characterised by extremely limited state provision and funding, with a heavy reliance on informal care from families.

Since then, increased spending has helped formal LTC services to develop in Southern and Eastern countries at the same time that Northern and Western countries have slowed or even cut back on spending.

This has led to a three-tier Europe, characterised by high levels of public expenditure and coverage by Northern European countries, medium expenditure and coverage by many Western countries and low expenditure and coverage by Mediterranean, Central and Eastern European countries and Ireland.

LTC coverage and access

Coverage of formal LTC varies widely. Coverage is comparatively low in several Central and Eastern European states, particularly of home and community based services. Relatively few European countries have quality management or regularly systems in place.

Population ageing and the consequent increased demand for formal LTC services has led to public services being restricted towards those with the highest levels of caring needs. As such, access in practice is limited by financial constraints and budget ceilings, leading to longer waiting times. Co-payments in many Southern and Eastern countries are often high, often costing almost 100% of services. Waiting lists to access services have become longer, ranging from three to four weeks to six months.

Long-term care workforce

Throughout Europe, and globally, formal LTC is not typically seen as an attractive sector for work. Difficult working conditions and low pay often generate high turnover among workers, contributing to a negative image of LTC, and creating difficulties in attracting highly motivated, highly qualified care staff. Overall, labour intensity in the LTC sector varies widely throughout Europe. Sweden and Germany have the highest ratio of formal workers against service users (1.1 and 1.0 respectively), compared with 0.19 and 0.15 in Estonia and the Czech Republic where formal LTC is still relatively under-developed. Moreover, qualification levels tend to be lower on average in relation to the healthcare sector overall, and the ratio of nurses to care workers is also low.

The gap in care supply is made up through the provision of informal supply by family and friends. The size of the family care workforce is at least double that of the formal care workforce (e.g., in Denmark), and in some cases it is estimated to be more than ten times the size of the formal-care workforce (e.g., Canada, New Zealand, United States, the Netherlands).

The economic contribution of (unpaid) family work ranges may be up to 36.8% of European GDP. In many Northern and Western European countries, support for informal carers (particularly the complementarity between formal and informal care services) is designed to allow them to reconcile their caring responsibilities with a professional career, and thus retain their salary and independence. In contrast, family members in Southern and Eastern countries have more intense caring responsibilities, which can limit them from having a viable career. At the same time, cash benefits for informal carers in these regions tend to be lower, which largely coincides with a legal obligation on family members to care for an older relative.

Challenges in LTC systems and EU policy responses

Respect of fundamental rights is a central priority for the current College of Commissioners of the European Commission, as is creating jobs in growing areas, including in the long-term care sector. These priorities are currently guiding the policy response to the many challenges faced by European countries in expanding the coverage of LTC services for older persons, particularly given labour market shortages.

The European Commission has shown significant leadership in encouraging all countries to plan for the changing age demographics throughout the EU, by sharing good practices, developing related policies and legislation and encouraging members to address basic human rights requirements by providing adequate access to affordable quality care. Proposals by the European Commission to Member States are to try to reduce demand for LTC through prevention initiatives, rehabilitation and the use of technology; and create incentives for informal carers to reduce the pressure on formal care services, alongside boosting efficient, cost-effective (formal) care provision at home and in residential care settings.

Two new European Commission proposals address the policy challenge in LTC: the New Start initiative, also known as the work-life balance initiative and the European Pillar of Social Rights tackle carers’ rights and LTC. The New Start initiative seeks to identify avenues for EU legislative action to effectively address women’s underrepresentation in the labour market. The European Pillar of Social Rights proposes to complement the EU’s social ‘acquis’ setting out principles to improve social protection mechanisms and fair labour markets. As established in its main principles in the area of adequate and sustainable social protection, health and LTC policies are aimed at ensuring access to adequate and affordable LTC with qualified professionals in a sustainable manner.

The European Semester as the main policy tool to address recommendations to Member States within the objectives of Europe 2020 has issued concrete recommendations on LTC in 2016. Both the Annual Growth Survey (AGS) and the Country Specific Recommendations (CSR) point out that reforms need to continue to make long-term accessible and cost-effective while maintaining a high quality of the services.

In 2016, nineteen Member States national reports mentioned LTC challenges. Eleven focused on scarce provision and coverage, making the link to insufficient female labour participation and sustainability issues. Besides the number of countries having reported challenges on LTC, the EC have only addressed two CSR, namely to Spain and Slovenia. The low number of recommendations may indicate a lack of attention to the sector. Although there is a stated commitment to fundamental rights, this does not often translate into attention in practice from the EU to human rights in LTC.

Although the availability of data has improved and life expectancy across the EU have risen, analyses of recent national policy reforms indicate that many Member State are not adequately planning for the future, but are instead “muddling through”, relying on informal care workers and/ or limited cash support for care recipients, which increases illegal migrant care. At the same time, many countries are expanding service provision through market mechanisms – contracting out state services to non-statutory (for- and non-profit providers). This highlights the complexities in developing the LTC sector and shows the need to ensure Member States’ human rights obligations remain high on the policy agenda.


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