Access to affordable high-quality long-term care 2022/C 476/01 - Main contents

EN

Official Journal of the European Union

C 476/1

Accessible, affordable and high-quality long-term care allows people in need of care to maintain autonomy for as long as possible and live in dignity. It helps to protect human rights, promote social progress and solidarity between generations, combat social exclusion and discrimination and can contribute to the creation of jobs.

In November 2017, the European Parliament, the Council and the Commission proclaimed the European Pillar of Social Rights (1), setting out 20 principles to support well-functioning and fair labour markets and welfare systems. Principle 2 promotes gender equality by fostering equality of treatment and opportunities between women and men in all areas. Principle 9 promotes the right to work-life balance for people with caring responsibilities. Principle 10 emphasises workers’ rights to a high level of protection of their health and safety at work. Principle 17 recognises the right of people with disabilities to inclusion, in particular to services that enable them to participate in the labour market and in society. Principle 18 on long-term care states that everyone has the right to affordable long-term care services of good quality, in particular home care and community-based services.

Long-term care services organised by public authorities, at national, regional or local levels, are primarily considered social services of general interest as they have a clear social function. They facilitate social inclusion and safeguard fundamental rights of all people in need of care, including older people.

Most carers are women according to the ‘2021 Long-term care report: trends, challenges and opportunities in an ageing society’ of the European Commission and the Social Protection Committee (2) (the ‘2021 Long-term care report’). The gender-based gap in the distribution of care work is one of the key drivers of gender inequality in the labour market. Women, on average, have lower incomes, including pensions, and are potentially less able to afford care, while at the same time living longer than men and thus being more in need of long-term care and exposed to a higher risk of poverty and social exclusion throughout their life time. Adequate and affordable formal long-term care services together with policies to improve working conditions in the sector and to reconcile paid employment with caring responsibilities could therefore be beneficial to gender equality.

This Recommendation promotes the application of Articles 21, 23, 24, 25, 26, 31, 33 and 34 of the Charter of Fundamental Rights of the European Union (3) covering non-discrimination, equality between women and men, the rights of the child, the rights of the elderly, integration of persons with disabilities, fair and just working conditions, and the rights to family and professional life and social security and social assistance.

This Recommendation respects the United Nations Convention on the Rights of Persons with Disabilities, which recognises the equal right of all persons with disabilities to live independently in the community, with choices equal to others.

The European Pillar of Social Rights action plan, adopted by the Commission on 4 March 2021, announced an initiative on long-term care with the aim of setting a framework for policy reforms to guide the development of sustainable long-term care that ensures better access to quality services for those in need, and encouraged Member States to invest in the health and care workforce, improving their working conditions and access to training.

The 2021 Long-term care report highlights that the demand for high-quality long-term care is set to rise and that increasing its provision can contribute to gender equality and social fairness. That report identifies access, affordability, and quality as key challenges in long-term care, an appropriate workforce as key to meeting the rising demand for high-quality services, while highlighting that informal care often comes with neglected costs.

Population ageing is expected to increase the demand for long-term care, as decline in functional ability and the need for long-term care are associated with older age. According to the 2021 Long-term care report, the number of people aged 65 or over is projected to increase by 41°% over the next 30 years, from 92,1 million in 2020 to 130,2 million in 2050, while the number of people aged 80 or over is projected to increase by 88 %, from 26,6 million in 2020 to 49,9 million in 2050.

The COVID-19 pandemic has negatively affected long-term care systems and exacerbated many pre-existing structural weaknesses, in particular the lack of quality services and worker shortages, and highlighted the urgent need to strengthen the resilience of long-term care systems and to step up efforts to improve personal autonomy and facilitate independent living.

According to the ‘2021 Ageing Report – Economic and Budgetary Projections for the EU Member States (2019-2070)’ of the European Commission and the Economic Policy Committee, there are marked variations across Member States in terms of the level of public funding for long-term care, with some countries investing less than 1 % of GDP, and some others spending more than 3°% of GDP. In 2019, public expenditure on long-term care amounted to 1.7°% of the Union’s GDP according to that report, which is less than the estimated value of hours of long-term care provided by informal carers, estimated to be around 2.5°% of the GDP of the Union (4). In Member States with low public expenditure on long-term care, use of formal long-term care services is more limited. The growing demand for long-term care increases pressure on public expenditure, while also calling for improving the cost-effectiveness of long-term care provision, for example, via health promotion and preventive policies, better integration and targeting of services, collecting data and evidence, and using new and digital technologies. Policies conducive to the sustainable funding of long-term care are important for the sustainability of public finances, particularly in the context of an ageing population and decreasing workforce in the Union.

Relying heavily on informal care will not be sustainable and formal care needs and pressure on public budgets are expected to increase.

Social protection coverage for long-term care is limited and costs often represent a serious barrier to accessing long-term care. For many households, financial reasons are at the top for not using, or not using more, professional home-care services. Without adequate social protection, the estimated total costs of long-term care can often exceed a person’s income. While arrangements of social protection vary across Member States, in some, public support is available only to a small proportion of people with long-term care needs. Even when available, social protection is often insufficient, as even after receiving support, on average, nearly half of older people with long-term care needs are estimated to be below the poverty threshold after meeting the out-of-pocket costs of home care.

Many people cannot access the long-term care they need due to, among other reasons, an overall low offer of services and to the limited range of long-term care options and territorial gaps. In many Member States the choice of long-term care is limited. Where there is a choice, it is mainly between informal care, mostly provided by women, and residential care. The supply of home and community-based long-term care is still low. In addition, territorial disparities in long-term care provision makes equal access to long-term care difficult, especially in rural and depopulating areas. The choice is even more limited for persons with disabilities due to uneven accessibility of care services. While acknowledging the diversity of long-term care arrangements across the Member States, strong public networks of long-term care services providers, with adequate human and financial resources, can contribute to improving access to long-term care services.

In long-term care, quality depends on an effective quality assurance mechanism, which in many Member States is lacking or is under-resourced. Quality assurance is often insufficient in home and community-based care. While quality of residential care is more regulated, quality standards often focus on clinical outcomes and do not sufficiently address the quality of life of people receiving care and their ability to live independently. Even when quality standards are in place, their enforcement is not always effective, often due to an inadequate administrative set-up or lack of resources. Lack of high-quality standards applied strictly to both public and private care providers can lead to situations of neglect and abuse of care recipients and poor working conditions for carers A national quality framework for long-term care, adapted to national context and operational set ups, can help to address those challenges. Such a framework can be reflected into specific quality frameworks for various levels of provision and administration of long-term care or various care settings.

Long-term care has an important social value and job creation potential, but Member States struggle to attract and retain care workers inter alia due to inadequate skills, difficult working conditions and low wages. There are untapped opportunities to address workforce shortages in the sector. Such measures could include, according to national needs and circumstances, targeting part-time workers who want to increase their working hours, unemployed and inactive former carers, formal long-term care workers who want to delay their retirement and students. Without prejudice to the competence of the Member States to regulate the admission, including the volumes of admission, of third-country nationals for the purpose of work, exploring legal and ethical migration pathways for long-term care workers could potentially contribute towards addressing workforce shortages.

The skills required in the care sector are increasingly complex. Skills are a combination of knowledge, ability and attitude that enable an individual to perform a task or an activity successfully within a given context. In addition to traditional skills and competences, carers often need to have technological expertise relating to the use of new technologies, digital skills and communication skills, often in a foreign language, and skills to handle complex needs and work in multidisciplinary teams. Without appropriate education and training policies, including on-the-job training, the skills requirements can act for many as a barrier to enter or progress further in the sector.

Professional carers often experience lack of training on occupational health and safety, non-standard work arrangements, irregular working hours, shift work, gaps in social protection, physical or mental strains and low wages. Low coverage by collective agreements of long-term care workers and limited public expenditure in long-term care can contribute to low wages in the sector.

Certain groups of workers, including live-in care workers or domestic workers providing long-term care, face particularly difficult working conditions, including low wages, unfavourable working-time arrangements, undeclared work, inadequate social protection, and non-compliance with essential labour protection rules and irregular forms of employment. The 2011 Domestic Workers Convention (No. 189) of the International Labour Organization lays down basic rights and principles, and requires national competent authorities to take a series of measures with a view to ensuring decent working conditions for domestic workers.

Informal care has been essential in long-term care provision, as informal carers, mostly women, traditionally carry out the bulk of caregiving, often due to a lack of accessible and affordable formal long-term care. On the other hand, many people also choose to provide or to receive informal care as a matter of preference. However, providing informal care can negatively affect carers’ physical and mental health and well-being and is a significant obstacle to employment, particularly for women. That has an immediate effect on their current income, and affects their old-age income due to a reduced accrual of pension rights, which can be even more significant for carers with additional childcare responsibilities. Therefore, a good work-life balance and better reconciliation of work and care duties are necessary for all informal carers, both men and women. In addition, in some cases, informal carers do not have access to adequate social protection and do not receive sufficient direct and/or indirect support for their caregiving activities, including financial support. Measures supporting the validation of their skills can help those interested to transition to formal care activities. Children and young people with a chronically ill family member tend to have more mental health problems and more adverse outcomes with long term effects on their income and inclusion in society.

The organisation of long-term care differs across the Union. Long-term care is organised in an often complex system of services across health and social care and sometimes other types of support, such as housing and local activities. There are also differences in terms of the employment status of professional carers and in terms of the roles played by the national, regional and local levels of administration and by the public, private and cooperative sectors. Indicators used for monitoring long-term care also vary and administrative data are often not available or comparable at Union level.

Long-term care stakeholders include those in need of long-term care, their family members and organisations representing them, relevant authorities at national, regional, and local levels, social partners, civil society organisations, long-term care providers, and bodies responsible for promoting social inclusion and integration and for the protection of fundamental rights, including national equality bodies. Social economy bodies, including cooperatives, mutual benefits societies, associations and foundations, and social enterprises are important partners for public authorities in the provision of long-term care.

The European Semester process, supported by the Social Scoreboard, has highlighted the challenges in long-term care, resulting in some Member States receiving country-specific recommendations in that area. The guidelines for the employment policies of the Member States adopted by Council Decision (EU) 2022/2296 (5) underline the importance of ensuring availability of affordable, accessible and quality long-term care. The Open Method of Coordination for Social Protection and Social Inclusion aims to promote accessible, high-quality and sustainable long-term care and supports that objective through monitoring, multilateral surveillance of reforms, thematic work, and mutual learning. The Social Protection Committee developed a European quality framework for social services (6), including long-term care. However, there is still no Union comprehensive framework to guide national reforms in long-term care.

The Union provides many funding opportunities for long-term care, targeting different investment priorities in accordance with the specific regulations of the various funding programmes, which include the European Regional Development Fund (with priority focus on non-residential family- and community-based services), the European Social Fund plus, and its Employment and Social Innovation strand, the Just Transition Fund, Horizon Europe, EU4Health Programme, the Digital Europe Programme, technical support to improve the capacity of national authorities to design, develop and implement reforms through the Technical Support Instrument and the Recovery and Resilience Facility for eligible reforms and investments in the context of the recovery from the COVID-19 pandemic.

This Recommendation builds on Union law regarding transparent and predictable working conditions, such as Directive 96/71/EC of the European Parliament and of the Council (7), Directive (EU) 2019/1152 of the European Parliament and of the Council (8) and Directive (EU) 2022/2041 of the European Parliament and of the Council (9), regarding work-life balance, such as Directive (EU) 2019/1158 of the European Parliament and of the Council (10), and regarding health and safety at work, such as Council Directive 89/391/EEC (11), Council Directive 89/656/EEC (12), Council Directive 90/269/EEC (13), Council Directive 98/24/EC (14),

Directive 2000/54/EC of the European Parliament and of the Council (15), Directive 2003/88/EC of the European Parliament and of the Council (16), Directive 2004/37/EC of the European Parliament and of the Council (17) and Directive 2013/35/EU of the European Parliament and of the Council (18), which is applicable and relevant to long-term care.

In full respect of the principles of subsidiarity and proportionality and taking into account the diversity and different organisational set-ups of long-term care systems, including decentralised ones, this Recommendation is without prejudice to the powers of Member States to organise their social protection systems and does not prevent them from maintaining or establishing provisions on social protection which go beyond those recommended,

1.

This Recommendation aims to improve access to affordable, high-quality long-term care for all people who need it.

2.

This Recommendation concerns all people in need of long-term care, and all formal and informal carers. It applies to long-term care provided across all care settings.

3.

For the purpose of this Recommendation, the following definitions apply:

4.

It is recommended that Member States ensure the adequacy of social protection for long-term care, in particular by ensuring that all people with long-term care needs have access to long-term care that is:

5.

It is recommended that Member States continously align the offer of long-term care services to long-term care needs, while providing a balanced mix of long-term care options and care settings to cater for different long-term care needs and supporting the freedom of choice, and participation in decision-making, of people in need of care, including by:

6.

It is recommended that Member States ensure that high-quality criteria and standards are established for all long-term care settings, tailored to their characteristics and to apply them to all long-term care providers irrespective of their legal status. To that effect, Member States are invited to ensure a national quality framework for long-term care in accordance with the quality principles set out in the Annex and to include in it an appropriate quality assurance mechanism that:

7.

It is recommended that Member States support quality employment and fair working conditions in long-term care, in particular by:

8.

It is recommended that Member States, in collaboration, where relevant, with social partners, long-term care providers and other stakeholders, improve the professionalisation of care and address skills needs and worker shortages in long-term care, in particular by:

9.

It is recommended that Member States establish clear procedures to identify informal carers and support them in their caregiving activities by:

10.

It is recommended that Member States ensure sound policy governance in long-term care, including an effective coordination mechanism to design, deploy and monitor policy actions and investments in that area, in particular by:

11.

It is recommended that Member States communicate to the Commission, within 18 months from the adoption of this Recommendation, the set of measures taken or planned to implement it, building where relevant on existing national strategies or plans and taking into account national, regional and local circumstances. Where appropriate, subsequent progress reports should be based on relevant reporting mechanisms and fora, including those under the Social Open Method of Coordination, the European Semester and other relevant Union programing and reporting mechanisms, such as the national recovery plans.

12.

The Council welcomes the Commission’s intention to: