# EUR-Lex - 52013SC0041 - EN

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# 52013SC0041

**COMMISSION STAFF WORKING DOCUMENT Long-term care in ageing societies - Challenges and policy options Accompanying the document COMMUNICATION FROM THE COMMISSION TO THE EUROPEAN PARLIAMENT, THE COUNCIL, THE EUROPEAN ECONOMIC AND SOCIAL COMMITTEE AND THE COMMITTEE OF THE REGIONS Towards Social Investment for Growth and Cohesion – including implementing the European Social Fund 2014-2020 /* SWD/2013/041 final */**

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COMMISSION STAFF WORKING DOCUMENT

Long-term care in ageing societies -
Challenges and policy options

Accompanying the document

COMMUNICATION FROM THE COMMISSION
TO THE EUROPEAN PARLIAMENT, THE COUNCIL, THE EUROPEAN ECONOMIC AND SOCIAL
COMMITTEE AND THE COMMITTEE OF THE REGIONS

Towards Social Investment for
Growth and Cohesion – including implementing the European Social Fund 2014-2020

Contents

1........... Introduction. 3

2........... Expected growth in
long-term care needs. 5

2.1........ Demography. 5

2.2........ Dependency levels —
developments in health status. 6

2.3........ Conditions influencing
the capacity for independent living. 7

3........... Present supply of LTC
in the EU under different financing and delivery models. 8

3.1........ Considerable differences
in LTC provision. 8

3.2........ Data on current LTC
provision. 9

3.3........ Composition of LTC
provision. 11

3.3.1..... Mix and cost of formal and
informal care. 11

3.3.2..... Informal care. 11

3.3.3..... The public-private mix in
the delivery and financing of formal care. 12

3.3.4..... In-kind services versus
vouchers or cash benefits. 12

3.3.5..... Use of undeclared care and
immigrant carers. 12

3.4........ Typology of LTC provision
in the EU27. 12

3.5........ Typology of LTC systems
in the EU27: Spatial map and legend. 13

4........... Relative strengths and
limitations of different delivery models. 14

4.1........ Leaving it to families to
provide informal care for their ageing kin. 14

4.2........ Getting families and
households to pay out of pocket for their informal care needs. 15

4.3........ Providing support to
family carers. 15

4.4........ Replacing informal with
formal care in various models of LTC financing & delivery. 16

4.4.1..... Publicly financed public
provision. 16

4.4.2..... Social-insurance funded
care, delivered by private non-profit or for-profit providers. 16

4.5........ In sum.. 17

5........... Policy options for
addressing future LTC challenges. 17

5.1........ The overall challenge in
LTC.. 17

5.2........ The challenge for public
budgets. 17

5.3........ Policy responses needed
to tackle the challenges. 18

6........... Good practices in
Member States applying social investment approaches to LTC.. 20

6.1........ Comprehensive national
approaches. 20

6.2........ Prevention. 20

6.3........ Rehabilitation. 21

6.4........ Productivity and capacity
gains from innovation, including through use of ICT. 21

6.5........ Quality assurance. 21

7........... Contributions from
Europe. 22

7.1........ Prevention. 22

7.2........ Productivity and capacity
gains from innovation including through use of ICT. 23

7.3........ The European Innovation
Partnership Pilot on Active and Healthy Ageing (EIP AHA) 23

7.4........ Quality assurance. 23

7.5........ Public finances and
research. 25

7.6........ Possible follow-up actions. 26

8........... Conclusion. 27

9........... Annex. 29

9.1........ Productivity and capacity
gains from innovation including through use of ICT. 30

1. 
Introduction

This Commission Staff Working Document,
which is part of the Social Investment Package, deals with social protection
against the long-term care (LTC) risks that affect women and men if they
develop frailties or contract multi-morbidities as they age[1].

As one of the annexes addressing how social
investment at different stages of life can ensure better outcomes at lower or
similar levels of cost and staffing, this document also links to the annexes on
Investing in Health and on Social Services of General Interest.

It demonstrates that even late in life
there are strong arguments for a social investment approach to social
protection. If Member States where the number of very old people will triple in
the coming decades are to be able to offer sufficient social protection against
LTC risks they will need to find ways to contain the growth in the demand for
LTC provision while also raising the efficiency of care provision. Thus,
arguments focus on the economic and social returns that a determined strategy
of social investment can achieve through a combination of reduced disability in
old age, improved capacity of older people to manage functional limitations and
higher productivity in care delivery.

In line with the Guiding Principles on
Active Ageing adopted by the Council[2],
this document follows up the focus on independent living in the EY2012 on
Active Ageing[3].
Moreover, in support of the objectives of Europe2020[4], it suggests how one of the key
challenges of population ageing may be addressed.

Across the
European Union, long-term care for older people refers to a range of services
and assistance for persons who over an extended period of time are dependent on
help with basic activities of daily living (ADLs)[5] and/or instrumental activities
of daily living (IADLs)[6].
In Member States with extensive provision, social protection against LTC risks
also increasingly includes measures that help prevent, postpone or mitigate the
onset of LTC needs.

It is estimated that one in two women and one in three men will come
to need intensive long-term care as they age. The need for long-term
care arises as a result of disability, which is usually due to health problems.
But long-term care is organised and financed differently from acute health care
in all Member States. Whereas health care is almost exclusively dispensed by
health care professionals, a substantial part of LTC services is provided by
untrained informal family carers. Therefore, it makes sense to view LTC
provision as a combination of informal and formal care. Moreover, since social
services such as home help are an integral part of formal LTC services and
benefits, they also involve a skill-mix in staffing which differs from health
care.

Long-term care is a highly gendered issue. Older women have a higher
life expectancy and a different pattern of morbidity in old age, so most care
recipients are women (both in home and institutional care services)[7]. Moreover, the vast majority of
both informal and formal carers are women[8].

As a strand of social protection, long-term care provision is a
Member State responsibility. While EU countries set their own level of ambition
in LTC provision, they have also agreed a set of common objectives centred on
access for all to financially sustainable, high-quality long-term care. These
guide collaboration on LTC issues in the Social Protection Committee.

Differences between Member States in providing long-term care are
more pronounced than in any other field of social protection. While this can
make EU policy coordination more complicated, it also increases the potential
benefits of EU-level collaboration. Given that Member States are at very
different stages in their efforts to address the need for long-term care
services, Europe could potentially add significant value by pooling the cost of
research and development and by facilitating knowledge transfer and mutual
learning on better ways of mitigating dependency and delivering LTC services.

Population ageing is the key common challenge in this field for
Member States in the medium- to longer-term perspective. Over the next five
decades, the number of Europeans aged 80+, and at particular risk of developing
a need for LTC, is set to triple. In the same period the reservoir of potential
formal and informal carers will reduce significantly as the working-age
population will shrink, the number of women employed grow, retirement ages rise
and family and living arrangements change. Given that formal LTC provision
tends to be underdeveloped in several Member States at present and that Member
States with extensive long-term care services already find it difficult to meet
the demand, these prospects are daunting. Unless new, more effective ways of
addressing the care needs of older persons are developed, long-term care
services will be overwhelmed, and a huge gap will open between LTC needs and
the ability of social protection systems to meet them.

This paper examines how long-term care needs may develop given the
trends in demography and health. It describes the diversity of LTC provision
across the EU and discusses the strengths and limits of present LTC approaches
from a social protection perspective and in view of future challenges. It then
analyses policies and gives examples of good practices that could help Member
States meet the challenges and provide better protection against LTC risks.

It finds that there is a need for a longer-term strategy of social
investment combining policies of

(1) prevention, health promotion and rehabilitation with

(2) systematic productivity drives in care delivery and

(3) measures that raise the capacity of frail older people to manage
self-care and independent living.

It examines the extent to which such practices are already
successfully emerging and whether Europe can help Member States with the
further development and dissemination of policies of this sort.

2. 
Expected growth in long-term care needs

The scale of future needs for long-term
care services among older women and men will depend on three factors:

· 
the number of people in the age group 80+,
those most likely to need LTC;

· 
long-term care needs as a function of average
health status, i.e. the extent to which older people, as they age, are
likely to grow frail and develop multi-morbidities;

· 
the degree to which older people can manage
independent lives in spite of functional limitations.

The number of people aged 80+ can be
forecast with considerable certainty and is a given. Policy makers may
influence the two other determinants, particularly in the medium to longer
term.

The average health status in old age will
result from health determinants in individuals’ prior lives, including their
health behaviours and living conditions as they age, as well as from effective
medical treatments that preserve or restore physical and mental functions.

Their ability to live independently will
depend on the age-friendliness of environments and living arrangements and on
access to assistive technologies. Thus public policies need to focus not only
on how to meet long-term care needs, as seemingly dictated by demography, but
should adopt a more preventive stance, seeking to minimise the need for LTC
services.

2.1. 
Demography

People tend to live longer, and the
baby-boom cohorts are joining the ranks of the elderly. As a result the number
of Europeans aged 80+ is set to rise particularly fast. This so-called ‘ageing
of the old’ will be especially pronounced from 2030 to 2040. Between now and
2060, the number of people over 80 is expected to almost triple.

Development in number of people 65+ and 80 + in EU27, 2008-2060,
millions

Source: 2010 EUROPOP

Meanwhile, according to the 2012 Ageing
Report[9],
the EU27’s population of working age is expected to decline by 14.2 %
(2010-2060). Thus, EU Member States cannot rely on a general increase in labour
supply to meet the growth in long-term care needs that could result from a
tripling of the number of people aged 80+. Even if more people are recruited into
the workforce, there will be such competition for manpower that it will be very
difficult to attract enough extra staff to formal long-term care to match
growing needs. Moreover, the potential reservoir of informal carers, mainly spouses
and daughters or daughters-in-law[10],
will also be affected by strong structural trends. With the changes in the
structure of families and growth in female employment rates as well as higher
pensionable ages and later retirement for women, the availability of informal
carers will be limited.

2.2. 
Dependency levels — developments in health
status

The increase in life expectancy has been
accompanied by an increase in the occurrence of chronic diseases that can limit
the ability to handle some daily activities. Thus, the need for long-term care does not arise
from ageing itself, but is rather the consequence of the prevalence of frailty
and multi-morbidity and the degree to which this causes individuals to be
dependent on others for assistance with basic and/or instrumental activities in
daily living (ADLs, IADLs).

There is
an on-going debate on whether higher life expectancy increases the likelihood
of functional impairments. Looking at recent trends in severe
disability, the evidence is inconclusive: while data for a number of EU
countries showed clear reductions from the early 1990s to the early 2000s[11], for other countries, severe
disability among older people seemed to have increased[12]. Moreover, different data sets
found opposite trends (decline in Denmark, Finland,
Italy and the Netherlands; an increase in Belgium and Sweden; and mixed
evidence in France and the UK)[13].

Indicators of healthy life years measure
the number of remaining years that a person of a specific age can expect to
live without any severe or moderate health problems or acquired disabilities
(Eurostat, 2010). In 2009, men and women in the EU27 at age 65 could expect to
live more than half of their remaining years with a frailty or disability that could
affect their ability to manage instrumental and/or self-care activities of
daily living.

Source: Eurostat Statistics Database; Joint
Action European Health and Life Expectancy Information System (JA EHLEIS). http://dx.doi.org/10.1787/888932702936

The key question is whether, as life
expectancy increases, dependency levels in old age will increase, remain
constant or decrease. We do not yet know the extent to which the prevalence of
disability will be affected over the next decades, as possible changes in
health behaviours and new treatments take effect.

For instance, Carol Jagger[14] found that with increasing
life expectancy in the UK, there will be an increase in disability prevalence
by 2030. Other international evidence suggests however that the health of older
people in the EU will continue to improve.

Lafortune and Balestat[15] have convincingly
argued that, although different trends in severe disability have been observed among
countries, the scale of the increase in the number of people over 65 is bound
to lead to a rise in the number of severely disabled older people. A decline in
the prevalence of severe disability could mitigate this growth, but it will not
compensate for the large increase in the number of people in the age groups at
risk.

At this stage, it seems safe to assume that
the ageing of the population will lead to a significant increase in the
number of frail older people with functional limitations and disabilities. Still, as highlighted above, the
need and demand for long-term care is not just a function of the prevalence of
disability.

2.3. 
Conditions influencing the capacity for
independent living

The
extent to which physical and mental impairment means people becoming dependent
is influenced by a person’s perception of their ability to manage
despite functional limitations. It matters a lot whether people are encouraged
and enabled to cope.

The
ability to ‘age-in-place’ and avoid institutional care is usually beneficial
for the mental and physical health of older persons. This is also clearly
reflected in people’s preferences. If they develop a need for long-term care in
some form, the overwhelming majority of older people would prefer to have home
help and home care, enabling them to remain in their homes[16]. Four key factors influence the
likelihood of this happening:

People’s
  capacity for independent living is influenced by whether they live
  alone. The availability of mutual support when living with other
  household members greatly enhances the coping ability of frail people. If
  they live on their own, their need for outside support is more likely to
  become an issue. Still, much can be done to improve their ability to
  continue to handle most essential aspects of everyday living.
 Improving
  the age-friendliness
  of the homes of older persons can play a great part in their ability to
  continue living independently when they become frail and develop
  multi-morbidities. The ability to remain in one’s home depends to a great
  extent on whether risks are addressed, by removing obstacles and hazards
  in the home and installing facilitating devices. Raising older people’s awareness
  of what they themselves can do to take simple measures to avoid accidents
  and facilitate access can greatly improve their ability to cope.
 Assistive
  aids and modern
  ICT offer promising opportunities to enable older people to go on
  living independently and help informal carers in providing care while
  preserving their private and professional lives[17]. Automated toilets, walking
  and lifting aids, power utensils, monitoring and communication tools are
  among the aids available, and there are rapid advances in this field. Developments
  in standard Home appliances can be of immense importance: for
  instance the widespread use of micro-wave ovens has been a great help to frail
  older people, enabling them to prepare their own hot meals. Monitoring and
  reminding devices can provide support. Care can be managed remotely,
  helping people to maintain independence safely. Technological devices for older
  or disabled people are becoming available at affordable prices. They can
  help improve cognitive health, reducing isolation and facilitating a wide
  range of activities around the house. Public procurement policies can
  support such developments.
 Access
  to informal or formal
  home help and home care services if older people cannot quite
  manage on their own. Tailoring such support so that it underpins a person’s
  capacity for independent living is one of the key challenges for care
  providers, whether formal or informal. Carers can also use many new
  technology solutions to improve work coordination and to reduce workload
  and stress, so that they can plan and use their working time more
  efficiently.
3. 
Present supply of LTC in the EU under different financing
and delivery models
3.1. 
Considerable differences in LTC provision

The way in which long-term care is treated in
the social protection systems of EU Member States varies greatly, notably in
the relative weight assigned to formal and informal care. There is also
marked diversity in the way formal care is organised (e.g. by public,
for-profit or NGO providers), financed (e.g. via general taxation,
obligatory social security, voluntary private insurance or out-of-pocket
payments) and delivered (e.g. as home care or institutional care).

In all Member States, informal care
provided by relatives plays a significant role in the overall volume of long-term
care provided. But there is enormous variation in the degree to which affordable
formal services have been developed and are made available.

Formal LTC services may be provided in a
variety of settings, including institutions, from traditional old people’s
homes to modern nursing homes, in supported living arrangements (e.g.
residential care) or people’s own homes (e.g. home help or home care). Long-term
care may cover different mixes of health care and social services.

Several countries offer cash benefits or
vouchers that can be used to pay for LTC services delivered by professional
care providers and, in some cases, by informal carers. In countries where
untrained family members can be contracted as informal carers and receive an
allowance for the care they provide, the distinction between informal and
formal care is blurred.

There is no consistency in the legal
framework for providing long-term care across the EU. In many Member States, extended
families are obliged to provide and/or finance care for their elderly
relatives. But countries differ in the extent to which they enforce this legal
responsibility and monitor whether care needs are actually met[18]. Where formal provisions are
well-developed, the rules about when people in need of long-term care have an
enforceable right to certain types and amounts of care are rather dissimilar.

At one end of a wide spectrum, some Member
States (see clusters E and F of the typology of European LTC systems in 3.4) basically
or primarily still rely on families to tend to all of their elderly relatives’ needs
for long-term care. Families cope either by acting as informal carers
themselves, or by arranging external help and financing it out-of-pocket. There
is no or little pooling of risks across families through formal social
protection.

A large number of Member States (see clusters
A, B and C of the typology of European LTC systems in 3.4) have developed some
formal long-term care services and secured at least partial collective financing,
either through social insurance schemes or through revenues from general
taxation. Yet, the accessibility, affordability and quality of these formal LTC
services differ considerably.

At the other end of the spectrum, a handful
of countries (see cluster A of the typology of European LTC systems in 3.4) with
four decades of experience in providing extensive care seek to take
comprehensive and integrated approaches to social protection against LTC risks
in old age. Such approaches include aspects of other public health policies, such
as preventive measures, active and healthy ageing, promoting autonomy and the capacity
to live independently through e.g. assistive aids for self-care, provision of
health and social LTC services, and end-of-life or palliative care.

3.2. 
Data on current LTC provision

Comparable data at EU27 level on the current
provision of formal and informal long-term care for elderly people are rather
sparse.

For the purpose of the projections in the
2012 Ageing Report[19],
the picture of present public expenditure for long-term care has been assembled
from data agreed by Member States (see Figure 1)[20]. In this scenario-building
exercise, informal care is generally viewed as being of no direct cost to the
public budget, whereas formal provision is understood to involve public expenditure,
calculated as the sum of publicly financed benefits in kind and in cash for
long-term care purposes.

Public spending ranges from 4.5 % of
GDP in DK to 0.2 % in CY or by more than a factor 20. The average for the
EU27 is 1.8 % of GDP. SE, NL and DK are high-spending countries, with more
than twice the EU average of their GDP devoted to long-term care. Five Member
States spend between 2 % and 2.5 %, seven countries are in the 1-1.5 %
range, nine in the 0.5-0.8 % span, and the remaining three spend 0.3 %
or less.

Fig. 1 Public expenditure on long-term
care as percentage of GDP in 2010, all ages

Source: based on
data from the 2012 Ageing Report.

These variations in public expenditure on long-term
care mainly reflect differences in the ‘coverage’[21] of formal systems of home care
and institutional care. The estimates of coverage illustrate both the varying
extent to which people with care needs receive formal LTC services and
differences in the use of home care and institutional care. Some countries
report little home care and also seem to have relatively limited ability to
respond to demand for institutional care. Some countries like DK, LT, NL and SE
show relatively impressive coverage rates in both types of provision (see cluster
A of the typology of European LTC systems in 3.4), while a few rely
predominantly on one or the other (see cluster D of the typology of European
LTC systems in 3.4). In 2010, the UK, EL, IE, LU, AT, DE, FR and IT seemed to rely
relatively more on home care, while institutional coverage rates, though moderate
overall, were relatively higher in countries like CZ, BG, SI and HU.

3.3. 
Composition of LTC provision
3.3.1. 
Mix and cost of formal and informal care

Public long-term care expenditure largely depends on how much a
country relies on formal care. Formal and informal care can be substitutes or
complements, depending on the type of care and needs. While formal care is recognised
as costly, both for the economy and the exchequer, informal family care also entails
both opportunity costs and regular costs for families. Family care involves
costs for the economy and the public budgets, as informal carers may not be
able to find or stay in formal work, and may thus pay little or nothing in taxes
and social contributions. Cost differences may also relate to differences in
the quality and productivity of informal and formal care delivery.

Some countries (e.g. in clusters E and D of
the typology) combine a de facto emphasis on informal care with a legacy
of traditional institutional care, in the form of old people’s nursing homes. Still,
most of these countries are transforming their nursing care models from
institutional to community-based care and home care as part of a movement to
de-institutionalise long-term care.

3.3.2. 
Informal care

In most European countries, a large part of LTC for older people is
provided by informal care-givers[22].
Even in countries with a well-developed supply of formal LTC, using narrow
definitions of informal carers, the number of informal care-givers is estimated
to be at least twice as big as the formal care workforce.

Over 90 % of people providing informal
care on a regular basis have a family relationship to the people they care for.
Informal carers are typically spouses, middle-aged daughters or daughters-in-law[23]. The share of people providing
some care is higher in northern Member States than in most southern ones. But
in the south, informal care involves a larger share of heavy care with ADL,
whereas help with IADL dominates informal care-giving in the north. When family
carers only provide additional care, pressures may be lighter[24]. Estimates suggest that the
economic value of unpaid family care as a percentage of the overall cost of long-term
care in EU Member States ranges from 50 % to 90 %[25].

Informal carers can be under considerable stress as they try to
balance work and family duties, and most have received no training in caring
for the elderly. Family care can entail substantial economic sacrifice, as
informal carers may be forced to cut down their working time or leave paid
employment altogether. Obligations to look after elderly relatives can cause
poverty, not just while care is being provided, but also later, if care-givers
are unable to build up sufficient pension rights.

In northern Europe, being an informal carer is not associated with a
significant reduction in employment. This is because of good access to formal
care support and policies enabling people to combine work and family
responsibilities. In southern Europe, informal caring duties often mean cutting
down on paid work, taking only part-time work, or early retirement. A similar
pattern, though somewhat less pronounced, is found in some Member States in central
Europe.

3.3.3. 
The public-private mix in the delivery and
financing of formal care

Member States use different
combinations of financing and care providers. Long-term care can be
organised as part of public health and social services financed by general
taxation and provided by public sector workers, as in Denmark and Sweden, for instance.
It may also be organised primarily via compulsory social insurance, as in
Germany or Austria. Here, care services are provided mainly by non-profit
organisations and financed by direct payments from the insurance authority or
through cash allowances and vouchers for care recipients. Out-of-pocket private
payments are more common for institutional care than for home care. For-profit
providers have a minor role, though they exist in all Member States, and may
play a significant role in the UK. About half of Member States regulate long-term
care provision mainly at national level, and the rest share responsibility
among central and lower-level authorities.

3.3.4. 
In-kind services versus vouchers or cash benefits

Cash-for-care benefits support individual choice regarding care
received, while in-kind services may facilitate public authority control over
the price/quality ratio. Cash-for-care benefits are particularly prevalent in a
number of Member States. Some countries provide both in-kind services and
cash-for-care benefits.

3.3.5. 
Use of undeclared care and immigrant carers

The underdevelopment of formal long-term care services
in southern Member States has given rise to the practice of families employing
immigrants — including some without legal status — as undeclared live-in carers
for their ageing relatives. In Italy, migrant live-in carers are estimated to account
for about three-quarters of all home-carers[26].
Such practices are also increasingly common in some central European countries
(e.g. AT and DE[27]),
though on a smaller scale.

Migrants also make up an increasing proportion of formal-care
workers in Member States with extensive services, especially where staff
shortages have encouraged them to develop policies to attract migrants in a
controlled way. Big differences in pay and working conditions among Member
States influence the inflow of mainly female migrant workers.

3.4. 
Typology of LTC provision in the EU27

Recent comparative research under the 7th Framework
Programme suggests that rather than viewing EU27 variance in LTC provision as a
continuum from large to small it makes more sense to view it as clustered into
a number of variations that can be organised into a typology of delivery
models. Building on a clustering developed by the ANCIEN project[28] for 21 countries, an overview of
the key differences between the 27 Member States can be obtained by organising them
into a typology of five modes of long-term care delivery.

3.5. 
Typology of LTC systems in the EU27: Spatial map
and legend

Nature of the system || Countries || Characteristics

Cluster A Formal-care (FC) oriented provision, generous, accessible and affordable || Denmark, The Netherlands, Sweden || Public provision of LTC financed from general revenue allocations to local authorities High public and low private spending on FC Low Informal Care (IC) use, high IC support Modest cash-for-care benefits

Cluster B FC of medium accessibility Some informal care (IC) orientation in provision || Belgium, Czech Republic, Germany, Slovakia, (Luxembourg) || Obligatory social insurance against LTC risk financed from contributions Medium public and low private FC spending High IC use, high IC support, Modest cash-for-care benefits

Cluster C FC of medium to low accessibility Medium IC orientation in LTC approach || Austria, England, Finland, France, Spain, (Irland) || Social insurance against LTC risk financed from contributions or general revenue Medium public and private FC financing High IC use, high IC support High cash-for-care benefits

Cluster D Low FC accessibility Strong IC orientation in LTC approach || Hungary, Italy, (Greece), (Poland),  (Portugal), (Slovenia) || Modest social insurance against LTC risks Low public and high private FC financing, High IC use, low IC support, Low cash-for-care benefits

Cluster E Rather low FC accessibility Almost exclusive IC orientation in LTC approach || (Bulgaria), (Cyprus) (Estonia), (Lithuania), (Latvia), (Malta), (Romania) || Little social insurance against LTC risks Very low public spending on FC Very high IC use, little to no IC support No or very low cash-for-care benefits

Thus, the
taxonomy on the page above suggests clustering based on a combination of
variables such as: the relative importance of formal and informal care; the
accessibility, generosity and quality of formal care; the relative role of
public, non-profit and for-profit formal care providers; the financing of
formal care; the size of cash-for-care benefits; support for informal carers;
reliance on live-in undeclared carers; the emphasis on traditional
institutional care in older peoples’ homes; etc.

4. 
Relative strengths and limitations of different
delivery models

In a stylised appraisal of the relative
strengths and limitations of present approaches to social protection[29] against the risks of
developing a need for long-term care in old age, a number of points stand out.
The following review of the range of current policy mixes focuses on the ways in
which informal and formal care are financed, organised and combined[30].

4.1. 
Leaving it to families to provide informal care for their ageing kin

Traditionally, societies have relied on the
moral commitment and willingness of families to provide support for their older
relatives, if they develop functional and mental limitations. This is the main
approach only in a minority of Member States. But in all Member States,
informal care plays a substantial role in care provision for older people.

Key advantages of this approach include the seemingly low costs to public budgets;
and care is likely to be provided by closely related and (generally) trustworthy
carers, so is likely to be well-intended. Moreover, the public sector does not
have to organise the financing, monitoring or delivery of such care.

Drawbacks:
the near absence of direct public expenditure does not mean that family care is
free. It comes at significant cost to families (i.e. primarily women as
spouses, daughters or daughters-in-law) in terms of the working time of the
carer, alternative employment income foregone and reduced accrual of social
protection entitlements. There may also be out-of-pocket payments for care
tools and assistive devices.

The principle that every family is expected
to care for its own family members also implies that there is no sharing of the
burden/cost of care across families. In this approach, there is no pooling of
the long-term care risk. Those with relatives in need of care do not receive
any public support. Those with ageing relatives that can manage without LTC do
not share in the societal LTC burden.

The rights of older people in need of LTC
will therefore depend on the ability and willingness of their families to
provide them with care. There are few, if any, means to influence the quality
and appropriateness of care that untrained informal carers provide. Neither the
quality nor the sufficiency of informal care can be guaranteed. Neglect and
even abuse may occur for lack of family resources to provide care, or as an
unintended consequence when family carers are exposed to the physical and
mental stress of being alone with care duties and to the social hardship this
may involve.

For society, family care involves opportunity
costs as carers reduce their labour force participation and contribute less to
GDP. In addition, the physical and mental stress and social hardship that
informal care-giving can induce may hamper the future health status and material
well-being of the care-givers themselves. The rather limited possibilities for improving
productivity means that informal care delivery remains highly labour-intensive.

In short, when fully analysed, this approach
has serious deficiencies in terms of equity, opportunity costs and efficiency.

4.2. 
Getting families and households to pay out of
pocket for their informal care needs

A variation on this model involves the
family hiring someone from outside the family to provide informal care, possibly
even taking on the role of live-in carer.

Key advantages: There is no public involvement in financing and organising
long-term care. This can be seen as a solution to care needs if families are
unable to provide care themselves, or if formal services are unavailable or
unaffordable. Family members need not miss out on employment opportunities. On
the contrary, they are likely to have paid employment to pay for the live-in carers.

However, as this approach tends to involve undeclared
work — and by illegal immigrants — there are indirect costs in taxes foregone.
While the hired carers may prefer this work to the alternatives open to them, their
services are affordable because they are clearly underpaid and do not earn
entitlements to social protection. In some Member States where live-in migrant
carers deliver a substantial part of LTC provision policy makers have sought to
mitigate these problems by legalising and formalising such arrangements. As
above, the downsides are that the quality of care cannot be guaranteed, and
prospects of better productivity and quality are very limited.

4.3. 
Providing support to family carers

Another option is for the authorities to
organise support for informal care. This may entail economic support, through a
contract involving a cash allowance for care performed, or crediting of social
protection entitlement, as well as training and care leave. It can also involve
offering protection in legislation or collective agreements to help reconcile
informal care duties with formal employment for family carers[31].

Key advantages are that the willingness and ability of family members to provide
informal care is harnessed at relatively limited costs to public
budgets, while some social protection pooling of the LTC risk is secured. There
is some quality assurance and some monitoring that needs are in fact met. Training
and care leave takes significant pressure off carers, which may have positive
effects on the quality of care provided by the family. The likelihood of the
primary carer leaving her employment may be reduced, especially if some formal
respite care is available when necessary[32].

The drawbacks are less of a concern than
in the other variants relying on informal care. But the cost to families can
still be considerable and there is only limited risk pooling for LTC needs. Unless
support covers home adaptations and support for assistive devices, productivity
improvements are still likely to be limited.

4.4. 
Replacing informal with formal care in various
models of LTC financing & delivery
4.4.1. 
Publicly financed public provision

The greatest involvement of the public
sector is found in those Member States where LTC is financed from general tax
revenue, organised as a public service and delivered by trained public sector workers
to those who need care. This is then an individual
right (e.g. DK and SE). In those countries, most LTC services take the form of
home help and home care, while nursing care is reserved for people suffering
from severe mental and physical limitations.

Key advantages include: a solid financing base with full pooling of LTC risks
across the population; maintenance of a larger formal workforce contributing to
GDP; jobs with upgrading opportunities for lower-skilled workers; well-trained
professional carers; and alleviation of the burden on families, so that people
with dependent elderly relatives can continue full-time employment. The rights
of those needing care are far better protected. Quality can be fully monitored
and there are opportunities for growth in productivity, including through
re-engineering and capital substitution[33].
Taking care into the formal sector unlocks it from the constraints of families
and makes the cost of delivering long-term care far more visible and amenable
to public policies.

Drawbacks
are that it tends to involve far higher public spending on long-term care (though
not necessarily much higher societal cost) and that public authorities assume
the bulk of the responsibility of social protection against long-term care risks
in old age. Confronted with constrained choices between various spending items
addressing the different needs of different categories of citizens, policy
makers face the difficult task of securing affordable quality care while
offering decent pay and working conditions to publicly employed professional
carers. Obviously, the supply and quality of care (and protection against the risks
of becoming dependent) may fall short of needs and expectations. Public budget
constraints can have an immediate negative impact on the amount and quality of
care provided. Moreover, the lack of a direct link between the financing of
care and entitlements can weaken the sustainability of systems and the ability
of older people who need long-term care to enforce their rights to definite
amounts of care of appropriate quality.

4.4.2. 
Social-insurance funded care, delivered by
private non-profit or for-profit providers

In this variant, non-profit NGOs such as
welfare associations and faith-affiliated social service organisations deliver
the bulk of formal care. For-profit providers may also have a role, but in most
Member States, this is rather limited and primarily concerns residential or
nursing home care. Services may be paid directly by a social insurance body or
may be payable with vouchers or care allowances provided to care recipients.

Advantages:
Generally, this approach can lessen the burden on families, as is the case in countries
with public provision, though in some Member States, it coexists with an
emphasis on informal care, for which it may also provide some financing. Where
social insurance is mandatory, it provides broad risk-pooling and a rather
solid financing base. Expenditure is covered by earmarked social security taxes
and is therefore less open-ended than in systems with financing from general
revenue. Entitlements tend to be easier to enforce as they are backed by
contributions and may entail clear definitions of the amount and type of care
to be provided to people with certain diagnoses of dependency. An environment
with more types of care providers can allow more consumer choice and may result
in competition, with a positive impact on quality and cost. It may also make long-term
care a more attractive field of employment, as professional carers can build careers
with various types of employers.

Drawbacks:
Contributions are levied on a somewhat narrower tax base than general revenue
and will have to be raised as needs increase. Reimbursements, care allowances
and vouchers may not cover the total price of care, thus requiring some
out-of-pocket payments by recipients or their families. The separation between
financing and care-providing bodies makes quality control more complicated, but
may generate incentives to productivity drives. Preventive measures, such as
home adaptations and access to day-care facilities may not be (fully) covered.
Access to rehabilitation may not be covered or fully reimbursed.

4.5. 
In sum

Current approaches to social protection against long-term care risks
differ widely in terms of risk pooling and equity in access.
Policies also differ markedly in their capacity to optimise the quality and
efficiency of care delivery. Approaches with a heavy emphasis on family
care are at a particular disadvantage in relation to these key dimensions of care
provision. Given future challenges these disadvantages are set to become major
deficiencies.

In many Member States, public expenditure is at present only the tip
of the iceberg when it comes to calculating the societal cost of caring for
frail older people in Europe. Expanding formal services, leading to higher
public expenditure, will result in hitherto hidden costs becoming visible, with
social protection to cover long-term care being developed to share the risks of
disability in old age more equitably. Importantly, it will not be possible to ensure
equality of access to long-term care, guarantee its quality or develop
productivity unless most of the current informal care is lifted into the formal
sector.

5. 
Policy options for addressing future LTC challenges
5.1. 
The overall challenge in LTC

Over the next five decades, the shrinking of the population of working
age will tend to limit economic growth and make it more difficult to recruit
formal carers. Changes in living and family arrangements, a rise in female
labour force participation rates and higher retirement ages will reduce the
reservoir of informal carers. At the same time, the threefold increase in the
number of those in the age groups most likely to need long-term care is likely to
lead to very substantial growth in demand for such care. In short, the
challenge is to find ways to contain the growth in demand for long-term care while
improving the capacity to provide more, better care with fewer human resources and
less funding.

5.2. 
The challenge for public budgets

The Ageing Report 2012, which examines the challenge in terms of its
impact on public spending, expects that the steep rise in the number of people
aged 80+ will generate a substantial increase in needs for long-term care, raising
pressure to expand care provision. The effect of ageing itself is expected to
result in at least a doubling of public spending on LTC for the EU27, i.e. from
1.8 % to 3.6 % of GDP in the period 2010-2060 (as shown by the
so-called ‘base case scenario’).

It is therefore important to find ways to limit the growth in public
spending, while avoiding a rapidly widening gap between the need for care and
the supply available.

5.3. 
Policy responses needed to tackle the challenges

National policy makers are seeing the future challenge for long-term
care as that of ‘closing the gap’ between growing care needs and stagnant to
shrinking resources. The key questions are finding policy mixes that can enable
Member States to close that gap. Important contributions towards doing so could
conceivably come from:

· 
raising the productivity of care delivery

· 
reducing the incidence and overall prevalence
of frailty and disability

· 
reducing dependency, i.e. enabling older
people to continue to manage independent living with functional limitations

The first element in a coherent strategy
concentrates on possibilities for delivering more, better care with fewer
resources in terms of manpower and money. The others focus on containing the
growth in needs for long-term care, through measures to prevent morbidities or
to slow their disabling course, while enabling elderly people to manage without
care, or with far less care than today, despite functional limitations.

The productivity of care
provision can be raised through better organisation, financial incentives, quality
control and re-engineering including through capital substitution. Current
change and innovations suggest that productivity growth will be far greater than
assumed in standard labour economics. Systematic productivity drives will be
limited to formal long-term care and it will therefore be important to replace
informal by formal care. But support for family carers, through ICT and
assistive devices, for instance, can also help raise both the productivity and
quality of informal care.

Active and healthy ageing and a determined
emphasis on prevention and rehabilitation can reduce the
incidence of frailty, postpone its onset and reverse or mitigate the course of
frailty, functional limitations and disability. People who are fit when they become
old and seek to remain physically and mentally active not only have a better
chance of avoiding or postponing frailties, they are often also better at
managing functional decline when it occurs.

General prevention and health promotion
schemes for all ages, with special awareness programmes for people in their 50s
to very old people hampered by functional limitations, can be built into social
protection. Avoiding premature erosion of physical and mental fitness and
damage inflicted through mal-medication and accidents such as falls would bring
large benefits, both in cost savings and quality of life. It will be important for
prevention policies to target some of the main diseases/physical conditions
that cause dependency. Another priority would be to promote early detection of emerging
limitations and frailties, and to offer mitigating measures, including
assistive aids. A wide range of preventive measures and policies have been
demonstrated to be clinically effective. Encouraging senior citizens to
participate in physically and mentally stimulating activities in various settings,
such as universities, language schools, sport centres, volunteering
organisations and day care centres, can halt the course of decline and help
maintain and sharpen faculties[34].

A fall leading to a broken hip or a spell
of serious illness can send an otherwise fit older person into rapid decline,
requiring extensive care. But cost-effective rehabilitation has
proved to be possible even in late stages of life. Obviously, rehabilitation is
most effective if provided immediately after an incident, before serious
frailties set in. Several Member States have included rehabilitation in their long-term
care approaches as a cost-effective tool, although this is not yet standard
practice.

Physical and mental restrictions in older
people need not be perceived as ill health and a threat to their ability
to lead independent lives as long as sufficient resources are available
to compensate for the deficits. It will be crucial to make the necessary social
investments in age-friendly adaptations of older people’s private homes and in
new assistive devices, including those that allow for self-monitoring,
self-care and self-management. This is about empowering and enabling older
people with functional limitations to manage a higher degree of
self-sufficiency. ICT can facilitate social interaction with family and friends
and allow for emotional support, even when people are largely bound to their
homes and relatives do not live nearby. Public procurement can be used to
secure assistive devices at affordable prices. Public policies can also
encourage older people and their relatives to pay out-of-pocket for assistive
devices to help older people look after themselves day-to-day. The aim would be
to enable and empower older people with functional limitations to get by with
much less long-term care than today, so that they can retain autonomy with
choice and dignity despite the physical and mental effects of ageing.

Well-known concepts such as ‘ageing in
place’, ‘continuity in care’, ‘care integration’ ‘self-care’ and ‘smart homes’
would be part of strategies that can successfully begin to tackle future challenges
in long-term care. Social experimentation followed by dissemination and scaling
up of successful approaches have for some time formed part of long-term care
strategy development in Member States such as DK, NL, SE and the UK. Ageing in
place, independent living and rehabilitation can be achieved through
age-friendly environments, assistive technology and appropriate provision of
home help and home care.

For some countries with well-developed
formal provision, focusing on prevention, productivity and independent living
will seem a logical extension of present efforts. Others will have to make substantial
changes. If risks are to be effectively shared and individual needs guaranteed,
genuine social protection programmes covering long-term care will have to be
developed. This will involve shifting care from the informal to the formal
sector to develop the productivity and quality of care delivery systematically.
It will entail making visible the hitherto hidden privatised cost of long-term
care. But it will also offer the prospect of substantial GDP growth and higher
employment rates. This way, Member States can benefit in major ways from
formalising and modernising their LTC provision.

Key questions for further investigation would be:

· 
To what extent can prevention and rehabilitation
affect the incidence and course of frailty and disability in old age?

· 
To what extent can systematic productivity
drives in care delivery, including thorough capital substitution and service
innovation, bring possibilities for delivering more and better care with less
manpower?

· 
How much potential is there for raising the
capacity of frail older people to manage independent living through age-friendly
adaptations, smart technologies and assistive devices?

· 
Would a combination of these complementary
approaches, which require determined social investments over a long period, be sufficient
to bridge the gap between the need for long-term care and the supply?

Obviously, these
questions cannot be fully answered in this paper. But a review of some good
practices in Member States can give an insight into the potential of a social
investment approach to the long-term care challenge.

6. 
Good practices in Member States applying social
investment approaches to LTC

Key elements of the necessary strategy are already emerging in
several Member States. This chapter summarises some good practices[35] in preventive
approaches to healthy and active ageing, successful rehabilitation,
efforts to improve the capacity for independent living, support
for informal carers and the use of ICT in drives
for higher productivity. Practices reviewed also include measures
to create more age-friendly environments, including support for home
adaptations, and efforts to raise quality in both formal
and informal care provision.

6.1. 
Comprehensive national approaches

In Sweden, policies have begun to combine the complementary
strategies of (1) productivity drives, (2) health-promoting and preventive
measures and (3) investments in home adaptations, ICT and assistive devices to enable
older people to continue living independently even after developing functional
limitations. National policies are increasingly oriented towards using
combinations of efforts in these three areas to bridge the gap between care
needs and provision, which would otherwise grow larger over the next 30 years. It
is estimated that systematic efforts of this sort over a long period can enable
Swedish municipalities to continue to meet demand for long-term care.

In Denmark, where long-term care is provided by local
government, the municipality of Fredericia[36]
realised that the age profile of its population in 15 years’ time would make it
very difficult to meet long-term care needs through existing approaches. It decided
to embark on a new strategy to encourage and enable elderly people to live independently
for as long as possible. Experiences with a so-called ‘rehabilitation for
everyday life’ approach demonstrate that with teams of physiotherapists and
ergonomists, it is possible to bring many older people from needing care on a
regular basis to basic self-sufficiency and autonomy. Through combining preventive
measures of active and healthy ageing, greater productivity in care delivery can
be achieved. While raising the ability of frail elderly to manage independently,
Fredericia has documented the possibility of raising the overall quality of
protection against LTC risks. In addition, job satisfaction for formal care
staff can be improved at lower costs, with fewer staff. Some of these
innovative approaches are becoming part of overall policy approaches in areas
of the UK and Germany.

6.2. 
Prevention

A preventive approach is preferable to acute and reactive care, not
only in financial terms but also regarding the individual’s health status. Encouraging
older people to remain independent in their home and community, while staying
socially active, can bring significant savings in the short, medium and longer
term. Prevention should be regarded as an investment, as also exemplified by
the ‘Re-ablement’ approach discussed in the Annex. Integrated care based on
collaboration within health care services and among social, health and
community care providers results in better outcomes for older people, while
addressing resource efficiency and sustainability. This is illustrated by the LinkAge
Plus programme cited in the Annex.

Health promotion and prevention also
involve quality assurance in different aspects of care. Studies have shown that
17 % of older people use at least one inappropriate medication and that
almost 60 % of older out-patients take medications that are suboptimal or
lacking an indication[37].
Adverse drug reactions or events (ADRs or ADEs) include falls with or without
fractures and more general geriatric syndromes (e.g. cognitive impairment,
urinary incontinence, etc.).

6.3. 
Rehabilitation

Although not yet common practice, rehabilitation at an early stage, properly
used, has proved to be cost-effective in long-term care and highly beneficial
for patients. Research[38]
has identified general success factors for rehabilitation programmes. In-patient
geriatric care should be combined with out-patient geriatric follow-up, based
on early recognition of patient needs. Frailer participants generally benefit
from individualised interventions, while group interventions are successful for
the less severely disabled[39].
An effective rehabilitation programme must start with a multidimensional
geriatric assessment in which problems are identified and recommendations are
drawn up. Monitoring should ensure that recommendations are properly
implemented.

Successful innovative practices have been developed for strokes, traumatic
brain injury and hip fractures. In most cases, respiratory rehabilitation and
cognitive rehabilitation can now be implemented. In some Member States,
rehabilitation is clearly identified as a specific service (e.g. Germany, see the
Annex), whereas in others (e.g. England, Denmark, Sweden and the Netherlands)
it is an integrated part of comprehensive programmes of health care and health
promotion.

6.4. 
Productivity and capacity gains from innovation,
including through use of ICT

The use of ICT (information and
communication technologies) to support carers and increase the productivity of
care delivery is spreading in Member States and gradually moving from the
experimental stage to being scaled-up, thus innovating and improving the way
care is organised and delivered and the way home environments are adapted[40] [41].

Social and ICT innovations enable new ways
of organising society around active ageing and independent living for older
people, as shown by the CARICT project for all of Europe (see Annex) and by examples
from Scotland, England and Italy. These new approaches have all brought higher
productivity and substantial savings while raising the quality of services as
well as the quality of life of older people with LTC needs and their carers.

6.5. 
Quality assurance

Quality assurance in LTC remains a major
challenge in a context of workforce shortages, the complexity of delivery and
the difficulty of monitoring. However, some Member States have already made
major efforts to improve quality, combating elder abuse and promoting the
professionalisation of long-term care delivery. In the field of prevention of
elderly abuse, the Dutch policy (see Annex) stands out as particularly
innovative and thorough. The implementation of the recent Borloo Plan in France,
which covers various aspects of the organisation and delivery of LTC, stands
out as a key initiative to tackle a multitude of weaknesses in provision by
launching a comprehensive national approach.

This brief review of innovative approaches
to providing long-term care emerging in Member States illustrates the potential
returns from pursuing innovation-driven social investment strategies and their
potential in efforts to avert a crisis in unmet needs as the number of old
people grows.

7. 
Contributions from Europe[42]

The EU can offer Member States significant
support in their efforts to tackle present and future challenges in LTC. The
diversity of systems is a major opportunity for mutual learning, for which the
EU can act as a facilitator. A number of policy departments are already
involved in these matters and involved in facilitating the exchange of
experience among Member States and stakeholders.

7.1. 
Prevention

Healthy ageing and independent living have
been promoted in Member States as part of the European Year 2012 for Active
Ageing and Solidarity between Generations. Upon joint suggestion from the
Social Protection Committee (SPC) and the Employment Committee (EMCO) the
Council on 6 December 2012 adopted Guiding Principles for Active Ageing, which
highlight the following policies as key routes to autonomy and independent living
in old age: Health promotion and disease prevention; Adapted housing and
services; Accessible and affordable transport; Age-friendly environments and
goods and services; Maximising autonomy in long-term care.

The Active Ageing Index (AAI)[43]
is a new monitoring tool developed by the European Centre Vienna in
collaboration with the United Nations Economic Committee for Europe (UNECE) and
the European Commission’s DG Employment, Social Affairs and Inclusion. The
index measures the performance of countries in four domains that together
determine active ageing potential: (1) employment of older workers; (2) social
activity and participation of older people; (3) independent and autonomous living
of older persons; and (4) an environment that enables active ageing. The index
aims to help shape future research and policy agendas and influence how
existing large-scale data-sets are developed to address the impact of
population ageing by following the policy discourse on active ageing and
solidarity between generations.

Taken together, these policies, already
developing in Member States, to some extent with comprehensive commitments to
social protection against LTC risks in old age, are a promising social
investment approach to containing the growth in LTC needs while raising the
ability of older people to live independently. Importantly, EU policies can
underpin the further roll-out of such policy efforts at national level. There
has been collaboration on LTC issues at EU level over the last decade, notably
in the Economic Policy Committee (EPC) and the Social Protection Committee
(SPC).

7.2. 
Productivity and capacity gains from innovation
including through use of ICT

ALIAS (AAL Joint Programme[44]) has developed a mobile
robot system that interacts with elderly users and provides assistance in daily
life, promoting healthy ageing and independent living.

Public procurement policies and new European instruments for long-term
investment can help establish the environment for large-scale European
production of innovative assistive devices at affordable prices.

DG CNECT has for decades followed technology developments that can help
tackle LTC challenges and promote independent living. DG CNECT is involved in
work on moving from innovation to production and marketing, and scaling up and
implementation in public policy. Together with DG SANCO, it leads the EIP pilot
on healthy and active ageing. DG CNECT also co-funds projects such as the
CARICT Project[45]
at the EC JRC[46].
This project documents the role played by ICTs in supporting informal carers. InCasa (ICT-PSP) has developed an ICT-based system to protect
frail elderly persons and prolong the time they can live well in their own
homes.

7.3. 
The European Innovation Partnership Pilot on
Active and Healthy Ageing (EIP AHA)

This initiative aims to identify and remove
barriers to innovation in health and long-term care delivery. By intensifying
work between all stakeholders on innovative solutions, it seeks to increase our
ability to scale up good practices and secure faster, large-scale deployment of
new knowledge and technology. The overarching objective is to extend average
healthy life years in the EU by 2 years by 2020. The partnership brings
together various stakeholders from the demand and supply side and promotes the
development of innovative products that contribute to healthy ageing and
facilitate the independent living of frail older people. The focus is on three
areas: (1) prevention and health promotion, (2) health and social care for
older people and (3) active ageing and independent living of older people
supported by innovative products.

The ICT research programme has for decades
supported technology developments to help tackle LTC challenges and promote
independent living. The Competitiveness and Innovation Programme supports
moving from innovation to production and marketing, and scaling up and
implementation in public policy.

The Lifelong Learning Programme and its
successor will help facilitate independent living by providing funding for the
acquisition of ICT skills by seniors.

7.4. 
Quality assurance

In the SPC, Member States
have compared approaches and exchanged experiences in relation to common
objectives of guaranteeing access for all to adequate long-term care, while
promoting quality and ensuring that adequate, high-quality long-term care
remains affordable and sustainable. In the Joint Reports on Social Protection
and Social Inclusion, Member States have reported on their approaches and
recent progress towards the common objectives. Various peer-reviews on LTC in
the Member States have provided opportunities for mutual learning. Member
States have also sought to agree a set of common indicators for measuring
advances towards the common objectives, and in 2008, the SPC adopted a special
report on LTC. The SPC has also agreed a European Quality Framework for social
services of general interest, including LTC services. Still, LTC has remained
the least-developed of the social protection strands for which Member States
have agreed common objectives. Recognising this, the SPC has recently stepped
up its work on LTC issues in its subgroup on ageing issues in social protection
SPC-WG-AGE. This group is currently considering a proposal for a major work
programme on Innovative Approaches to LTC, which may run till the end of 2013.

Beyond the work of these committees, LTC
issues have been covered in the Research Programmes of the EU and
in work on the potential of ICT developments to care for older people and
ensure independent living. The Ambient Assisted Living Joint Programme
(AAL) aims to enhance the quality of life for older people. It funds projects
using intelligent products and the provision of remote services, including care
services, to improve the lives of older people at home, in the workplace and in
society in general. It has a total budget of around EUR 700 million for the
period 2008–13, sourced approximately 50–50 from public (national and EU) and
private bodies.

As part of its servicing of the SPC and the
Social OMC, DG EMPL has accumulated extensive experience on LTC.
The unequal distribution of LTC needs has been connected to health inequalities
and arduous working conditions. Long-term care has been considered in
opportunities for job growth and the future supply of jobs for the low-skilled
(see the April 2012 Employment Package[47]).
In future, the structural funds, including the ESF, are expected to give more
attention to health and social inclusion issues, entailing wider possibilities
to use the funds. New orientations in social policy towards social
experimentation also offer prospects for innovation and improvement in
long-term care provision.

DG JUST’s Daphne programme deals with elder abuse. An act on accessibility is
planned. The gender equality roadmap includes a proposal to develop a directive
on leave for carers.

The European Parliament has given particular attention to the LTC-related issue of Neglect
and Abuse of Older People and allocated money to research and NGO projects on
policies to prevent and tackle the danger of such violations of the basic
rights of frail older people. The AGE Platform is one of the organisations that
have examined the issues and come up with proposals for a preventive approach
in the WeDO project.

The Lifelong Learning Programme and its
successor will continue to provide funding for the acquisition of skills and
competences by carers, whether formal or informal, as well as funding and tools
for the recognition and validation of the skills acquired.

Important OECD work on
financing and staffing issues in LTC and on quality assurance has been co-funded
by the European Commission[48].

7.5. 
Public finances and research

DG ECFIN, cooperating with Member
States in the Ageing Working Group of the EPC, has
focused on how age-related increases in public expenditure for long-term care may
affect the stability of public finances. A methodology has been developed for collecting
a set of data and carrying out public expenditure projections for long-term
care over several decades. Results have been reported every third year since
2006 in the Ageing Report. Furthermore, a working paper elaborating on the
Ageing Report[49],
focusing specifically on LTC, has just been published in the Economic Papers
series[50].

The EU and Member States have also launched
two specific Joint Programming Initiatives (JPIs) aimed at facilitating active
and healthy ageing.

The More Years, Better Lives JPI addresses
the challenges and opportunities of demographic change by developing
multi-disciplinary knowledge as the basis for future research, innovation and
policy making.

The Joint Programming on Neurodegenerative
Disease Research (JPND) aims to increase coordinated investment among 13 participating
countries in research aimed at finding causes, developing cures, and
identifying appropriate ways to care for those with neurodegenerative diseases,
in particular Alzheimer’s. As such, it will improve understanding of these
diseases and contribute to ensuring early identification and treatment thus reducing
the social and economic impact for patients, families and health care systems.

Five thematic priorities for future
research include: the origins of neurodegenerative disease; disease mechanisms
and models; disease definitions and diagnosis; developing therapies, preventive
strategies and interventions; and healthcare and social care. A joint
transnational call was launched in December 2012 to address the evaluation of
current health care policies, strategies and interventions for
neurodegenerative diseases.

Additional funding for research on
Alzheimer’s is provided through the Innovative Medicines Initiative (IMI), a
EUR 2 billion public–private partnership between the European Commission (FP7)
and the European Federation of Pharmaceutical Industries and Associations
(EFPIA). PharmaCog is a pan-European partnership of experts working on
delivering high-quality Alzheimer’s medication. The EMIF (European Medical
Information Network) project has the goal of creating a common information
framework of patient-level data that will link up and facilitate access to
diverse medical and research data sources. One of the two areas addressed will
be Alzheimer’s, with a view to identifying the mechanisms that make some people
more susceptible to the disease than others.

In the 6th and 7th
Framework Programmes for Research DG Research has furthermore
financed projects on health systems and LTC issues (e.g. ANCIEN, INTERLINKS,
SHELTER, COURAGE, RightTime PlaceCare, REFINEMENT, MentDis_ICF65, etc.)[51]. Projects centre on needs
mapping, quality measurement, LTC delivery, role of financing systems in quality
of care, development of best practices in long-term care organisation, and
specific mental health issues in old age.

With the Administrative Committee,
the European Commission is currently examining how Regulation 883[52] on the coordination of social
security systems can be revised to ensure better long-term care coverage for
mobile persons. As social protection for long-term care needs is increasing in
importance, the EU social security coordination rules have to take these
developments into account. In 2012, the Commission launched an Impact
Assessment to analyse the different options for revised rules on the coordination
of long-term care benefits. The aim is to enhance the effectiveness of the
coordination regime, improve the social security protection of vulnerable
citizens wishing to live in another Member State and improve legal certainty
for all stakeholders. The Commission plans to finalise the Impact Assessment at
the end of 2013 and to launch the revision in 2014.

7.6. 
Possible follow-up actions

Together, these initiatives and activities by
the European Commission and other EU institutions form a framework of potential
support for developing social protection against LTC risks. There are thus
substantial possibilities at European level to offer help to Member States in
introducing innovative social investment-oriented approaches to providing
long-term care.

Steering role of the SPC WG-AGE

The immediate task at EU level should be to
make more connections between these initiatives and activity areas and raise
synergies between them. Developing the SPC-WG-AGE into a focal point for
LTC-related activities across Commission services could be a first step. With
regular reporting to Member State delegates in the SPC-WG-AGE from initiatives
run by different services, a functional inventory of LTC activities could
emerge and the interaction between these improved.

A programme of work has been proposed with
contributions from experts, Member States and Commission services leading to an
SPC report on Innovative approaches to social protection against LTC risks.
This would entail involvement of or contact with external partners whenever
required.

The intention is to organise knowledge
generation and best practices exchange to explore avenues to innovative, better
social protection against LTC risks in view of the shared OMC goals. Ideally,
such social protection would consist in a continuum of policies from early
prevention to practical delivery of LTC, including the role of informal care.
Thematic meetings would include a keynote address from an expert followed by
presentations from one or two Member States with particular experience in the
topic under investigation. Each of these would be used to introduce discussions
and exchanges of expertise between delegates.

Among the key
challenges for policy makers and stakeholders, this proposal for a work
programme focuses on the following:

- limiting
the growth of LTC needs through prevention, rehabilitation, and increased
capacity for independent living

- ensuring
access to LTC services for those in need

- securing
the quality of care

- maintaining
the financial sustainability of LTC delivery

In order to address these issues, a
sequence of thematic working meetings is set out. At each step, the involvement
of DG SANCO is clearly required, and for each topic covered the gender
dimension should be clearly addressed.

Expected contribution from JRC-IPTS

A new JRC-IPTS project for 2013-14 aims to
support DG EMPL in helping Member States to develop long-term care strategies
promoting independent living of older adults — especially frail adults —
through technology-based solutions. These solutions cover any kind of
technology, including ICT, that empowers clients to manage despite frailties
(self-sufficiency), better organises the provision of care or increases the
productivity and quality of long-term care delivery (capital substitution for
care manpower).

The main objective is to produce guidelines
for the Member States to design long-term care strategies than can increase the
capacity of older adults for independent living even when they become frail or
contract multi-morbidities, with the use of technology and based on the case
studies of good practices. This project will have the following specific
objectives:

To identify good practices in technology-based
  services and solutions for independent living at home for different needs
  of older adults, which have been successfully implemented.
 To analyse the good practices case by case in
  terms of business case, business model, technology and
  organisational change, technical standards, quality, scale and
  scale-up, and national and EU role for leadership and transfer.
 To produce a manual for policy makers on
  long-term care strategies for policies to increase the capacity of older
  adults for independent living with the use of technology.
 To identify the role of the EU in supporting
  Member States in implementing these technological services.

The specific added value of this project is
helping decision-makers make an informed choice on this important topic, also
from an economic and technical point of view and with regard to their own LTC
delivery situation. The approach is definitely pragmatic and policy-oriented.

8. 
Conclusion

Europe needs to prepare for a tripling of the number of people in
the age group where people are most likely to need long-term care. The current
modes of responding to older people’s long-term care needs are not sustainable
in view of this major demographic shift. This paper has tried to highlight ways
of responding to this challenge by reducing the need for long-term care through
prevention, rehabilitation and the creation of more age-friendly environments,
and by developing more efficient ways of delivering care.

Social innovation and social investment are called for to develop
new ways of closing the gap between long-term care needs and provision. This
paper presents some promising examples of good practice from a range of Member
States. The EU can play a major role in promoting innovation and social
investment in this area, e.g. through the European Innovation Partnership on
Active and Healthy Ageing and the Ambient Assisted Living Programme. It can
mobilise the structural funds for boosting investment in age-friendly
environments and more qualified professional carers.

Progress towards financially sustainable and socially adequate
social protection against long-term care risks should continue to be monitored
by the EU’s Economic Policy and Social Protection Committees. A successful
response to the challenges of rapid growth in the number of people aged 80 or
over will be crucial for the dignity and quality of life of older people and their
relatives. It will also be decisive for achieving a number of goals set in the
context of the Europe 2020 Strategy — sound public finances in ageing
societies, a high level of employment and the reduction of poverty.

It is therefore suggested that future work with Member States on LTC
gives particular attention to a social investment-oriented strategy,
which combines preventive measures of healthy and active ageing with
productivity drives in care delivery and measures to increase the ability of
older men and women to continue independent living even as they become frail or
develop disabilities. Moreover, as increasing priority is given to the quality
of public expenditure in EU policy guidance through Country-Specific
Recommendations, these should also focus on improving the effectiveness of
spending in this area, so adequate social protection against long-term care
risks can be ensured even at the height of population ageing.

9. 
Annex

ACTION programme,
Sweden

The ACTION programme (Assisting Carers using Telematics
Interventions to meet Older people’s Needs) is directed towards frail elderly
persons who prefer to stay in their own homes, but are in need of support.

The ACTION service aims to strengthen the self-management
capabilities of older people and their families. By means of ICT, family carers
can get on-demand support from local service centres staffed with qualified
professionals. The service primarily helps informal family carers. Also,
networking and mutual exchange between service users is facilitated.

The service offers information, education and support to older
people and their family carers via the following channels: access to an
extensive information database about caring in daily life, services available
and coping strategies; physical and cognitive training programmes and
relaxation programmes; support and social company from other users via the
integrated videophone system; support and advice from skilled care
practitioners working in the call centre via the videophone system; individual
and group computer education about how to use the ICT-based service; and
comprehensive education, ongoing supervision and a certification programme for
care practitioners working in an ACTION call centre. The main outcome of this
service is a strong improvement in quality of life, reduction of isolation of
the patient and the carers, the improvement of carers’ preparedness, and
therefore reduction in the need for home help services and delayed entry to
nursing homes. The service is available to carers in several municipalities at a
low price[53].

Examples of
prevention

Prevention through the ‘Re-ablement’
approach in the UK[54]
aims to maximise independence and quality of life in older age, while reducing
costs, by aiming for the lowest appropriate level of care for individuals. Key
principles are: encouraging individuals to do things for themselves, focusing
on real practical outcomes within a specified timeframe, and continuous rather
than one-off assessment to decide on individual care needs (Allen and Glasby,
2009). One retrospective longitudinal study demonstrated that an average of 60
per cent of people leaving homecare re-ablement no longer required a homecare
package and, 24 months later, had still not required a homecare package.

Recently, the UK
Department for Work and Pensions (DWP) put in place the LinkAge Plus programme,
a scheme worth £ 10 million to improve the wellbeing of older people
through promoting stronger partnership, better information and access to
services, and putting older people at the forefront of service design and
delivery. The LinkAge Plus principles can be replicated in a variety of
contexts. Case studies demonstrate the potential of the approach and a business
case has been developed[55],
Taking falls as an example, on average, a fall resulting in a hip fracture
costs around £ 20 000 to the taxpayer. Evidence suggests that 15
weeks of balance classes reduces the likelihood of a participant falling by
around 50 per cent. This illustrative example suggests that each £ 1 spent
on balance classes by the taxpayer in LinkAge Plus areas could yield health and
social care savings of £ 1.35 plus benefits to the individual of around
£0.90, from improved longevity and quality of life. Combining the costs and
benefits of these services with a holistic approach to service delivery
increases the net present value in the example to £ 2.65 per £ 1
invested.

Examples of health
promotion

Based on existing
successful experiences over the last decade, the UK NHS created in 2011
the New Medicine Services[56]
(NMS, October 2011 until March 2013) to provide early support to long-term care
patients, to avoid inappropriate medication and to maximise positive benefits
to clients. At this stage, the evidence suggests that the NMS will deliver net
benefits of at least £ 210 million (discounted) in the worst-case scenario
(i.e. highest cost and lowest benefit) over a 10-year period. This is purely in
cash terms, and does not consider the potential wider health and economic
benefits of the NMS, or the notion that £ 1 saved from a health
intervention is worth £ 2.40. In the central scenario, net benefits are
estimated at £ 1.5 billion (discounted) over a 10-year period.

Examples of
rehabilitation

Germany: CARITAS Bremen[57] has developed a rehabilitative
approach as part of a programme that aims to support people moving back home,
with the help of a ‘bridging person’ (‘Pflegeüberleitungsperson’). An
innovative integrated care contract provides extended rehabilitative training,
e.g. after acute hospital admission, to restore the mobility of older people
and help them regain their autonomy and better cope with disabilities. The care
unit is located in a care home, close to the department of physiotherapy,
logo-therapy and occupational therapy. Following the programme, home care is
available for up to seven days after discharge.

9.1. 
Productivity and capacity gains from innovation
including through use of ICT

The CARICT project[58]
has investigated the potential impact of information and communication
technologies (ICTs) on formal and informal carers by looking at experiences
from a number of Member States. It documents that ICTs can offer a
cost-effective way to improve the quality of care provided to dependent older
people. ICT installations providing monitoring and assistive aids may allow
people in need of care to carry on with daily life activities without recourse
to continued formal or informal care. Key factors for success are care
coordination, personal support and social integration. The project also
documents that the burden on care-givers can be substantially eased by offering
access to training about health and care issues and care-giving to frail
people.

Telecare[59]
in Scotland covers a range of devices and services that use
technology to enable people to live with greater independence and safety in
their own homes.

Examples include devices that trigger a response from a call centre,
such as falls monitors and motion sensors. The responses may range from a phone
call to the person, to alerting a local carer, neighbour or social service or
alerting emergency services if appropriate. Other examples include devices that
directly alert the person in the home to a particular hazard, such as a water-level
monitor in a bath. IT developments are continually extending the range of
devices and services available and, as a result, there is much scope for
telecare to help older people with particular health and social care needs to
remain in their own homes and optimise their independence and quality of life.
Telecare (2006-2011) involved investments of £ 20 million, and is
estimated to have saved approximately £ 80 million. Nearly half of these
savings arose from avoiding care home admissions, while a similar figure arose
from avoiding hospital in-patient stays. Clients and carers are referred to
telecare by social services and/or by social workers or health professionals.
The trial period achieved its aims to increase the use of telecare in
mainstream service provision, improve assessment procedures for service users,
train service providers’ staff to incorporate telecare within care packages,
ensure telecare services are delivered to recognised standards, and enhance
innovation in telecare services. The Scottish government is now implementing a
new telecare/telehealth initiative running from 2012-2015, called Delivering
Assistive Living Lifestyles at Scale. This is intended as phase one of the
wider Scottish Assisted Living Programme, which will utilise new technologies
to support people with health and social care needs in their own homes.

E-Care[60] is as a pro-active case management service in operation since 2005
in Italy. The main objective of the E-Care project is to maintain
independent living for the elderly in their own homes through customised care
plans designed according to individual needs. E-care is a service organised as
a 24-hour/7-days-a-week call centre that offers a wide range of services
targeting physically frail or socially isolated elderly people aged 75+ living
at home. The service provides older people with information on health, social
care and social alarm services. A call centre functions as an intermediary
between the frail elderly and social and health care providers. On a regular
basis, an operator contacts the elderly to check their well-being, health
conditions and needs. In the case of a problem, the operator and the patient
decide together upon the action to take: intervention of a doctor or a
volunteer organisation for social support. A unique electronic file records the
basic individual history and a software platform allows for information-sharing
and data transfer between care services. The E-Care platform has also been used
to integrate services such as:

-
Uffa che Afa’ — an initiative set up to support vulnerable people during severe
heat waves

-
a tele-geriatrics service to support people who need care after hospital
discharge

-
a dementia-specific telecare service

-
the ‘Giuseppina’ service, which provides free home delivery of food and
medication as well as transport services to hospitals or social events

E-care
has reduced the number of hospital admissions and led to a decrease of 50 %
in users accessing hospital services.

Quality assurance in LTC

Framework
for the Prevention of Elder Abuse and
Neglect[61]:
The Netherlands has implemented an ambitious and very comprehensive
legal and institutional framework to fight elder abuse. The framework covers
all stakeholders and most dimensions of the phenomenon through initiatives in
10 areas:

1: Prevention (guide for municipalities on preventing elder abuse,
including a special initiative on financial exploitation)

2: Targeted information and awareness-raising for older people
on elder abuse

3: Screening of paid care staff, including via mandatory
certificates of conduct (VOG)

4: Toolkit on volunteers and elder abuse (awareness raising
and guidelines for conduct)

5: Reporting elder abuse to authorities (mandatory for abuse
by professionals, mandatory protocolling of abuse in home environments,
specific guidelines)

6: E-learning, training and education of care staff (in collaboration
with trade unions etc.)

7: Elder-abuse hotlines (established in centres for reporting
of domestic violence etc.)

8: Aid and support for victims following a report of neglect
or abuse

9: Support for victims of disruptions in informal care

10: Approach to perpetrators (principles for handling abuse cases: a
serious offence requiring a legal approach entailing intensified monitoring of
reported elder abusers; moreover, if professional care staff commit elder
abuse, the IGZ Assessment Framework stipulates that the care institution must
suspend the offender and that a report of criminal activities should be filed
with the public prosecution service, where appropriate.

[1]               LTC provision for children and working-age adults
with physical and mental disabilities falls outside the scope of this analysis.
The focus is on the probability that older people will need LTC and on
population ageing, which is likely to lead to a strong increase in the size of
those older age-groups at particular risk.

[2]               See: http://ec.europa.eu/social/main.jsp?langId=en&catId=89&newsId=1743&furtherNews=yes.

[3]               See: http://europa.eu/ey2012/.

[4]               See: http://ec.europa.eu/europe2020/index_en.htm.

[5]               ADLs: Activities of Daily Living are self-care
activities that a person must perform every day such as bathing, dressing,
eating, getting in and out of bed or a chair, moving around, using the toilet,
and controlling bladder and bowel functions.

[6]               IADLs: Instrumental activities of daily living
are activities related to independent living and include preparing meals,
managing money, shopping for groceries or personal items, performing light or
heavy housework, and using a telephone.

[7]               Hubert M. et al. (2009) Facts and Figures on Long-term
Care: Europe and North America, European Centre for Social Welfare Policy and
Research.

[8]               Ibid.

[9]               European Commission (DG ECFIN) — Economic
Policy Committee (AWG), 2012, ‘The 2012 Ageing Report — Economic and budgetary
projections for the 27 EU Member States (2010-2060)’, European Economy No
2/2012.

[10]              Hubert M. et
al. (2009) Facts and Figures on Long-term Care: Europe and North America,
European Centre for Social Welfare Policy and Research.

[11]             Lipszyc, B. et al. (2012), ‘Long-term care: need, use
and expenditure in the EU-27’, Economic Papers 469, November 2012, available
at:            http://ec.europa.eu/economy_finance/publications/economic_paper/2012/ecp469_en.htm.

[12]             Triantafillou J. et al, 2010, Informal care in LTC —
European Overview Paper, INTERLINKS report.

[13]             EU-SILC data quoted in ECFIN (2012) Long-term care:
need, use and expenditure in the EU-27, European Economy. Economic Papers. 469
also show a mixed picture for developments from 2006-2009.

[14]             MAP 2030 / Carol Jagger — University of Newcastle.

[15]             Lafortune and Balestat (OECD 2007).

[16]             ‘Health and long-term care in the European Union’,
Special Eurobarometer 283/wave 67.3, Dec. 2007.

[17]             JRC (2013) Can technology -based services support
long-term care challenges in home care? Analysis of Evidence from Social
Innovation Good Practices across the EU: CARICT Project Summary Report.
Authors: Carretero, S.; Stewart, J.; Centeno, C.; Barbabella, F.; Schmidt, A.;
Lamontagne-Godwin, F. and Lamura, G. JRC Scientific and Technical Reports
Series, EUR 25 695 EN, at:                http://ipts.jrc.ec.europa.eu/publications/pub.cfm?id=5899.

[18]             MISSOC: http://ec.europa.eu/social/main.jsp?langId=en&catId=815.

[19]             European Commission (DG ECFIN) — Economic Policy
Committee (AWG), 2012, ‘The 2012 Ageing Report — Economic and budgetary
projections for the 27 EU Member States (2010-2060).

[20]             Data are from the SHA and/or ESSPROS databases and/or
from Member States, and are agreed by Member States.

[21]             In the Ageing Report 2012 a proxy for ‘coverage’ is
constructed by calculating the number of recipients of formal LTC benefits in
cash and in kind reported by Member States as a percentage of people with
dependency needs as measured by EU-SILC. As people may receive both kinds of
benefit, the number of recipients may involve some double counting.

[22]             Triantafillou J. et al, 2010, Informal care in LTC —
European Overview Paper, INTERLINKS report.

[23]             Hubert M. et al. (2009) Facts and Figures on Long-term
Care: Europe and North America, European Centre for Social Welfare Policy and
Research.

[24]             Hubert M. et al., (2010) Informal carers: the backbone
of long-term care, European Centre for Social Welfare Policy and Research.

[25]             Triantafillou et al., 2010.

[26]             Lamura, G. et al., (2008), ‘Les travailleurs immigrées
dans le secteur de l’aide aux personnes âgées: l’example de l’Italie’.

[27]             Jandl, M., Hollomey, C. and Stepien, A. (2007),
Migration and Irregular Work in Austria — Results of a Delphi-Study,
International Migration Papers 90, International Centre for Migration Policy
Development, Geneva: ILO.

[28]             Kraus M. et al (2010), ANCIEN, A Typology of Long-Term
Care Systems in Europe. In the map on the following page the Member States
listed between brackets were not fully covered in the study.

[29]             The stylised approach simplifies actual policy mixes to
bring out essential differences. For an overview of country-linked policy-mix
typologies other than ANCIEN see Colombo et al.: Help Wanted, OECD 2011.

[30]             Outcomes of different policy mixes are also affected by
cultural (societal and individual) differences.

[31]             Dublin Foundation study.

[32]             Family carers may acquire knowledge, skills and
competences through their caring activities, which employers and unemployment
services could take into account if they are recognised, even though they have
been acquired in an informal way.

[33]             Re-engineering involves changing the way social
protection against the LTC risk is organised, e.g. through a greater emphasis
on prevention and empowering for self-sufficiency. Capital substitution entails
replacing and amplifying human labour by productivity-enhancing technology.

[34]             Susann Rohwedder and Robert J. Willis, Mental
Retirement, Journal of Economic Perspectives—Volume 24, Number 1—Winter 2010, pp.
119–138.

[35]             Please consult the Annex for further details.

[36]             See: http://www.fredericia.dk/Borger/Sider/default.aspx.

[37]             http://www.dh.gov.uk/health/2012/03/new-medicines-service/.

[38]             Reference to be added.

[39]             Reference to be added.

[40]             See: http://is.jrc.ec.europa.eu/pages/EAP/eInclusion/carers.html.

[41]             JRC (2013) Can technology -based services support
long-term care challenges in home care? Analysis of Evidence from Social
Innovation Good Practices across the EU: CARICT Project Summary Report.
Authors: Carretero, S.; Stewart, J.; Centeno, C.; Barbabella, F.; Schmidt, A.;
Lamontagne-Godwin, F. and Lamura, G. JRC Scientific and Technical Reports
Series, EUR 25 695 EN, at:                http://ipts.jrc.ec.europa.eu/publications/pub.cfm?id=5899.

[42]             This is only a brief summary. A fuller inventory of
European initiatives of relevance is given in here: www.ec.europa.eu/social/BlobServlet?docId=8710&langId=en.

[43]             See:         
http://europa.eu/ey2012/ey2012 main.jsp?catId=975&langId=en&mode=initDetail&initiativeId=186&initLangId=en.

[44]             The Ambient Assisted Living Joint Programme is a joint
research and development funding programme. Its main objectives are to improve
the living conditions of older people through the use and development of AAL
solutions based on ICT technologies, and to strengthen the competitiveness of
European industry in the AAL domain. For further information see: http://www.aalforum.eu/page/aal-joint-programme.

[45]             See: http://is.jrc.ec.europa.eu/pages/EAP/eInclusion/carers.html.

[46]             See: http://is.jrc.ec.europa.eu/pages/EAP/eInclusion/carers.html.

[47]             "Towards a job rich recovery", COM(2012) 173 final, "Exploiting the employment potential of
the personal and household services, SWD(2012) 95 final and "Action
Plan for the EU Health Workforce", SWD(2012) 93 final.

[48]             Colombo et. Al: Help Wanted, OECD 2011 and Colombo et
al.: MONITORING AND IMPROVING QUALITY IN LONG-TERM CARE IN OECD COUNTRIES,
forthcoming OECD 2013.

[49]             See for instance: European Commission (DG ECFIN) —
Economic Policy Committee (AWG), 2009, ‘The 2009 Ageing Report: Economic and
budgetary projections for the EU-27 Member States (2008-2060)’, European
Economy No 2/2009; European Commission (DG ECFIN) — Economic Policy Committee
(AWG), 2012, ‘The 2012 Ageing Report — Economic and budgetary projections for
the 27 EU Member States (2010-2060)’, European Economy No 2/2012.

[50]             Lipszyc, B. et al. (2012), ‘Long-term care: need, use
and expenditure in the EU-27’, Economic Papers 469, November 2012.

[51]             http://www.ancien-longtermcare.eu/;
http://interlinks.euro.centre.org/;
http://lnx.starcomitaliaweb.eu/; http://www.healthcompetence.eu/converis/publicweb/project/3075;jsessionid=5360e5766198167404d643735d2b?show=Person;
http://www.mentdiselderly.eu/; http://www.righttimeplacecare.eu/.

[52]             Regulation (EC) No 883/2004 of the European
Parliament and of the Council of 29 April 2004 on the coordination of social
security systems

[53]             The Telecare Development Programme in Scotland
2006-2011, (2011) New Heaven Research.

[54]             CSED Homecare Re-ablement Retrospective Longitudinal
Study, Social Policy Research Unit (SPRU), University of York, Acton Shapiro
research organisation.

[55]             Watt P. and Blair I. (2009).

[56]             Introduction of the New Medicine Service (2011),
Department of Health, Impact Assessment 5101, from http://www.legislation.gov.uk.

[57]             Kümpers S, et al., (2010) Prevention and rehabilitation
within long-term care across Europe, European Overview Paper.

[58]             JRC (2013) Can technology-based services support
long-term care challenges in home care? Analysis of Evidence from Social
Innovation Good Practices across the EU: CARICT Project Summary Report.
Authors: Carretero, S.; Stewart, J.; Centeno, C.; Barbabella, F.; Schmidt, A.,
Lamontagne- Godwin, F. and Lamura, G. JRC Scientific and Technical Reports
Series, EUR 25 695 EN, at: http://ipts.jrc.ec.europa.eu/publications/pub.cfm?id=5899.

[59]             See: http://www.scotland.gov.uk/Publications/2010/10/27154413/6.

[60]             See: http://www.ict-ageing.eu/index.php?s=E-care+Project.

[61]             See: http://www.preventelderabuse.eu/european/Multimedia/Get/186.