EUROPEAN COMMISSION Brussels, 7.9.2022 SWD(2022) 441 final COMMISSION STAFF WORKING DOCUMENT Accompanying the document Commission proposal for a Council Recommendation on access to affordable high-quality long-term care {COM(2022) 441 final}



Table of Contents 1.Introduction 2.Context of the initiative 2.1.Demographic trends 2.2.Social and labour market trends 2.3.The digital transition 3.State of play of long-term care – challenges in Member States 3.1.Organisation and financing of long-term care 3.1.1. Organisation of long-term care systems 3.1.2. Public expenditure on long-term care 3.1.3. Financing long-term care 3.2.Social protection for long-term care 3.2.1. Eligibility for social protection for long-term care 3.2.2. Coverage of social protection for long-term care 3.2.3. Adequacy of social protection for long-term care 3.3.Availability and accessibility of long-term care 3.3.1. Availability of long-term care services 3.3.2. Accessibility of long-term care services 3.4.Quality of long-term care

3.4.1. Defining the quality of long-term care 3.4.2. Quality assurance in long-term care 3.4.3. Drivers of quality 3.5.Long-term care workforce and informal carers 3.5.1. The long-term care workforce 3.5.2. Untapped job creation potential and labour shortages in the sector 3.5.3. Informal carers 3.6.Impact of COVID-19 on long-term care systems 4.Current Union support and the case for reinforced action at EU level 4.1.EU initiatives relevant to long-term care 4.2.EU analytical work 4.3.The social Open Method of Coordination 4.4.The European Semester 4.5.Funding opportunities at EU level 4.5.1. Structural funds 4.5.2. The European Agricultural Fund for Rural Development 4.5.3. The Just Transition Fund 4.5.4. EASI social innovation projects on long-term care 4.5.5. Technical Support Instrument 4.5.6. The Recovery and Resilience Facility

4.5.7. Horizon Europe 4.5.8. Digital Europe 4.6.Why and how the EU should act now 5.Policy options for addressing the challenges of long-term care 5.1.Social protection for long-term care 5.1.1. Providing adequate social protection for long-term care 5.1.2. Illustrating the impact of improving social protection for long-term care 5.2.Availability of long-term care 5.2.1. Expanding long-term care services 5.2.2. Illustrating the impact of expanding the availability of home care 5.2.3. Increasing access to long-term care via digitalisation 5.2.4. Strengthening the accessibility of long-term care 5.3.Quality of long-term care 5.3.1. Long-term care quality framework 5.3.2. Long-term care quality principles 5.3.3. Long-term care quality assurance 5.3.4. Drivers of quality improvement 5.3.5. Quality of informal care 5.4.Long-term care workforce and informal carers 5.4.1. Attracting a skilled long-term care workforce

5.4.2. Tapping into the potential of digitalisation 5.4.3. Measures to support informal carers 5.5.Long-term care governance and funding 5.5.1. Sound policy governance in long-term care 5.5.2. Investing in long-term care 6.Conclusion Annex 1Key Definitions Annex 2Quality assurance bodies and responsibilites



List of figures Figure 1: Share of people aged 65+ living in private households with a severe level of difficulty with personal care or household activities Figure 2: Expected median share of people 65 years and older by degree of urbanisation Figure 3: Public spending on long-term care as % of GDP, current and projections Figure 4: Share of expenditure by financing schemes for the health component of long-term care expenditure Figure 5: Share of potential dependants aged 65+ who receive public care or cash benefits Figure 6: Out-of-pocket costs of home care as a share of income (after public support), for care recipients with a median income and with no net wealth, by severity level

Figure 7: Share of the old age population that would be at risk of poverty after paying for the out-of-pocket costs of home care for moderate needs Figure 8: Main reasons for not using (more) professional home care services Figure 9: Number of (full-time equivalent) long-term care workers per 100 people aged 65+, 2019 Figure 10: Share of population 18-74 providing informal care, by gender Figure 11: ESF Investment priorities and operations (2014-2020) Figure 12: Simulated out-of-pocket costs of care, as a share of disposable income after public support, averaged across respondents who take up formal care services under policy scenario 1 Figure 13: Simulated out-of-pocket costs of care, as a share of disposable income after public support, averaged across respondents who take up formal care services under policy scenario 2 Figure 14: Dimensions of quality of life (The Netherlands) List of tables Table 1: Overview of EU-27 average outcomes, at baseline and under different policy scenarios Table 2: The potential of digital technologies in improving access to long-term care Table 3: The potential of digital technologies in improving the quality of long-term care Table 4: Potential drivers of quality improvement Table 5: The potential of digitalisation to support the workforce 1.Introduction ‘For nights on end [during the pandemic], we all stood at our windows and doors to applaud critical workers. We felt how much we relied on all those women and men who work for lower wages, fewer protections and less security. The applause may have faded away, but the strength of feeling cannot. This is why the implementation of the European Pillar of Social Rights is so important – to ensure decent jobs, fairer working conditions, better healthcare and better balance in people's lives. […] We will come forward with a new European care strategy to support men and women in finding the best care and the best life balance for them.’ President Ursula von der Leyen, 2021 State of the Union speech In her 2021 State of the Union speech, Commission President Ursula von der Leyen announced a European care strategy to support both carers and care receivers, from childcare to long-term care (LTC). The strategy sets out a holistic and lifelong vision for care that enables everyone to access and afford the high-quality care they need. It also aims to help improve working conditions in the care sector, close the gender employment gap, increase women’s empowerment, and make the most of the benefits of the ‘silver economy’ and digitalisation. The initiative will support the implementation of the European Pillar of Social Rights , notably principle 18 that states that ‘Everyone has the right to affordable long-term care services of good quality, in particular home care and community-based services’. It follows up on the European Pillar of Social Rights action plan, the gender equality strategy, and the Green Paper on Ageing , which highlighted the need for integrated and person-centred long-term care that is accessible, affordable and of high quality. It also respects the United Nations Convention on the Rights of Persons with Disabilities, which recognises the equal right of all persons with disabilities to live independently in the community, with choices equal to others.

The preparatory work for the initiative built on the 2021 Joint Report on Long-Term Care prepared by the Social Protection Committee (SPC) and the Commission (Directorate-General for Employment, Social Affairs and Inclusion). This report analysed the common challenges in related to the provision of long-term care and set out key messages on the way forward. In addition, several studies (e.g. Social protection in long-term care (by the OECD)) and EU publications (e.g. long-term care workforce (by Eurofound)) as well as European statistics provide the analytical underpinning for this staff working document. A range of collaborative processes in the context of the European Semester process and the social Open Method of Coordination enriched the knowledge base for the initiative. To complement this input, the Commission published a call for evidence and a targeted stakeholder consultation between February and April 2022. The initiative consists of a Commission Communication on the European care strategy, a Commission proposal for a Council Recommendation on access to affordable high-quality long-term care, and a Commission proposal for a Council Recommendation on the revision of the Barcelona targets on early childhood education and care. On long-term care, the aim is to address the common challenges and structural weaknesses that were highlighted by the COVID-19 pandemic. To do so, the Commission sets out a framework for policy reform to ensure better and more affordable access to high-quality long-term care services and improve working conditions in the sector. This staff working document provides the analysis and evidence underpinning the Commission’s proposal for a Council Recommendation on long-term care. It also illustrates the policy narrative on long-term care as formulated in the Commission Communication on the European care strategy. For the purposes of this document, long-term care means a range of services and assistance for people who, as a result of mental and/or physical frailty and/or disability over an extended period of time, depend on help with daily living activities and/or are in need of some permanent nursing care. The daily living activities for which help is needed may be the self-care activities that a person must perform every day (Activities of Daily Living, 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) or may be related to independent living (Instrumental Activities of Daily Living, such as preparing meals, managing money, shopping for groceries or personal items, performing light or heavy housework, and using a telephone). Following the introduction, chapter 2 gives the wider socio-economic and political context of the initiative. Chapter 3 summarises the common challenges of long-term care at Member State level and the status quo underpinning the initiative. Chapter 4 describes the current support and initiatives available at EU level. Chapter 5 identifies different policy scenarios and practical examples of policy responses to address the common challenges of long-term care. 2.Context of the initiative Care is one of the foundations of a social Europe. Policy developments in this regard are deeply inter-linked with demographic, social and labour market trends, as well as with the digital and green transition. Against the background of population ageing, geographic mobility, increased share of single person households and increasing women participation on the labour market, Member States are confronted with significant challenges to meet the increasing demand for long-term care. The COVID-19 pandemic has further exposed the structural weaknesses of long-term care systems. 2.1.Demographic trends Consistently low birth rates and higher life expectancy are transforming the shape of the EU’s age pyramid. Europe is transitioning to a population structure with more older people, a development which is already apparent in several EU Member States today. As a result of demographic change, the proportion of people of working age in the EU is shrinking, while the relative number of those retired is expanding. In 2021, more than one fifth (20.8%) of the EU’s population was 65 years and over, while young people (0 to 14 years old) made up 15.1 % and people of working age 64.1%. The share of people aged 65-79 years and over is projected to increase by 23% over the next 30 years, while the share of people aged 80 or over of the total population is projected to almost double. As a consequence, the old-age-dependency ratio is projected to increase significantly from 32.5% in 2021 to 52.0% in 2050. Despite progress in healthy life years, as well as in preventive approaches and use of digital technologies, the ageing of the population will lead to a growing need for long-term care. The prevalence of physical or mental disability, which increases with age, often leads to dependency on help with activities of daily living (ADLs) and/or instrumental activities of daily living (IADLs), thus corresponding to a need for long-term care. Although there is no single internationally accepted and standardised definition of what constitutes long-term care needs, Member States usually take into account the presence and extent of difficulties with personal care (ADLs) and household activities (IADLs). Thus, data from the European Health Interview Survey (EHIS) can be a proxy for the number of people in need of long-term care. On average, 26.6 % of people aged 65 or over and 39.4% aged 75 or over living in private households were in need of long-term care, according to 2019 data for the EU-27. These self-reported long-term care needs ranged from 11.6 % in Luxembourg to 56.5 % in Romania (see Figure 1 ). In the first (i.e. lowest) income quintile, 35.9 % were in need of long-term care, compared with 17.2 % in the fifth income quintile across the EU-27. Comparing data for 2019 and 2014 shows that self-reported needs for long-term care among people aged 65 or over slightly decreased from 27.2 % in 2014. Figure 1: Share of people aged 65+ living in private households with a severe level of difficulty with personal care or household activities Source: EHIS wave 3, 2019, hlth_ehis_tadle. Across the EU, according to the projections from the 2021 Ageing Report , the number of potential dependants of all ages, defined as people with a disability, is expected to rise from about 30.8 million in 2019 to 33.7 million in 2030 and 38.1 million in 2050, corresponding to an overall increase of 23.5%. In 2019, 17.0 million of those dependents (10.8 million women and 6.1 million men) were above 65 years old, a share of 55% of all dependants; however, this age group accounts for only 4% of the general population. Therefore, while acknowledging that people of all ages may require long-term care services, most of the statistical data in this document linked to long-term care concerns the group of older people 65 years and over. The demographic profiles of EU regions vary widely, notably between urban and rural areas, with some places ageing significantly and others expanding their working age population. However, the demographic projections of the Atlas of Demography show that patterns of ageing do not necessarily follow the urban-rural classification of territories (see Figure 2 ). Although rural areas have a higher share of older adults, there is no clear-cut pattern where rural areas would be ageing faster. The population is ageing faster in the areas affected by depopulation, including in some small towns and cities. In rural areas, the share of older people is projected to increase from 19% in 2011 to 30% in 2050. During that same time period, the share of older people would proportionally even increase more in towns (from 17% to 29%) and cities (from 15% to 27%). Consequently, the difference between the share of older people in rural areas and in cities could become smaller in several Member States over the next decades. Figure 2: Expected median share of people 65 years and older by degree of urbanisation Source: JRC Atlas of Demography 2.2.Social and labour market trends Old-age poverty or social exclusion slightly increased since the mid-2010s. Almost 20.2 % (18.1 million) of people aged 65 and above in the EU-27 in 2020 were at risk of poverty or social exclusion, while in some countries the share is much higher. The monetary poverty risks among older people have slightly risen over the past three years, while severe material and social deprivation has continued decreasing. Gender inequalities become more pronounced in old age. In the EU-27, the gender gap in old-age poverty is larger than in working age, and more so among those aged 75 and above (almost 1.4 pps, i.e. 16.8% among men, 18.2% among women). The gender pension gap caused by the aggregated impact of labour market inequalities remains significant (27.7 % in 2020 among those aged 65-79) despite a slight decrease (from 31.9 % in 2016).

More older women than older men are in need of long-term care, while being less able to afford it. Women live longer than men , and men tend to spend a greater proportion of their somewhat shorter lives in good health. In addition, women have lower earnings (including pensions) across the EU and are exposed to a higher risk of poverty or social exclusion in all Member States. At the same time, older women are more likely to live alone and thus may not be able to rely on support from other household members. Old-age poverty and social exclusion also aggravate older people’s loneliness and isolation, affecting their well-being and social engagement. This is often linked to poor access to social care and healthcare, transport and housing services. Loneliness increases the likelihood of admission to long-term care facilities and sometimes affects older people in need of long-term care, despite social activities, potential company with peers and the care provided. Women are increasingly participating in the labour market – a positive development in the context of the increasing importance of equality of opportunities, ageing societies and a decreasing working-age population. However, women also carry the bulk of informal caring activities (and almost 90 % of workers in the formal long-term care sector are women). Therefore, in 2020, 6.3 % of women aged 50-64 wanting to work did not seek employment due to caring responsibilities, compared to only 2.5 % of men in this age group. Informal carers play an important role in long-term care, as they provide an estimated 33-39 billion hours of care worth around 2.7% of GDP across the EU-27 (compared to public long-term care expenditure of 1.7% of GDP, see chapter 3). While older people were severely impacted by the COVID-19 crisis in general, the recovery on the labour market was more dynamic for older workers after the COVID-19 crisis than for the economy as a whole. After a dramatic contraction in 2020, the EU economy rebounded strongly in 2021 with an 1.4 pps increase of the employment rate after the earlier drop of 1 pps. Older workers aged 50-64 weathered the crisis better than average, as their employment rate only grew less fast, by 0.6 pps in 2020, than it did earlier during the 2010s (by a yearly 1.4-2.2 pps). As a result, their employment rate reached 60.5% in 2021 against 46.6% in 2012. Although the recovery was stronger for men than for women in this age group, employment rates of women grew more, by 37% over this period (vs 24% for men) reducing the gender employment gap from 14.2 pps to 12.7 pps. Changing and more diverse family structures and more individuals and couples remaining childless also lead to increased need for formal care services, as the traditional capacity of the family to provide informal care is decreasing. In 2020, 40 % of older women were living alone, double the share for men. While the total number of households rose by 7.2% between 2010 and 2020, single adult households without children grew by 20.3% across the EU. Moreover, households with two or more adults not being a couple (e.g. older person living with other members of the family, economically independent roommates), decreased by 7.4 % over the 2010-2020 period in the EU . Increased labour market participation by women, who are the majority of informal carers, means that they become less available to provide long-term care to others in their social environment. While increasing retirement ages grant higher pensions and allow providing better support, they also keep people busy working for longer. Adequate and affordable formal long-term care services and policies helping to reconcile paid employment with caring/familial responsibilities help meeting the rising demand for care and sustaining the growth in women’s labour market participation, while keeping in mind work-life balance and the health of all involved. 2.3.The digital transition Digital technologies, especially artificial intelligence, are transforming the world at an unprecedented speed and present manifold opportunities. They have changed our societies and our economies and are increasingly changing the way long-term care is provided. This includes fostering independent living, improving access to high-quality and affordable care, while tapping into the potential of the Single Market and facilitating upscaling of digital solutions for the benefit of people in need of care and their caregivers. Effective deployment of new technologies may also boost the efficiency of long-term care expenditure. The way the digital transition impacts the care economy is documented in recent research. The global market for ICT solutions for healthcare monitoring in private homes was projected to grow from nearly EUR 11 billion in 2016 to roughly EUR 32 billion by 2021, while the European market for robots and other devices assisting older people is estimated to be worth about EUR 13 million in 2016, with clear prospects for further growth . The growth of the platform economy in the recent years brought forth the development of digital care platforms, such as in private household childcare or care for older people. The size of the EU platform economy in the domestic and home services sector has grown to an amount of EUR 1.5 billion in 2020 from EUR 0.8 billion in 2016, and is expected to continue to expand in size. Digital labour platforms in the care sector provide a digital infrastructure to match supply and demand in the field of private household care. They provide a flexible and easily accessible way to access work in this field and facilitate access to care for consumers. Digital labour platforms can play an important part in formalising work in this sector. 3.State of play of long-term care – challenges in Member States Member States face similar challenges and structural weaknesses of care systems, which have been brought to the fore by the pandemic. The analysis in this chapter describes the status quo in Member States structured in five sub-sections: organisation and financing of long-term care systems, social protection for long-term care, availability and accessibility of long-term care, quality of long-term care, long-term care workforce and informal carers. Subsequently, chapter 5 builds on these identified common challenges by showcasing examples and opportunities how to address them. 3.1.Organisation and financing of long-term care There are substantial differences across the EU in terms of how long-term care is funded, organised, delivered and monitored. Member States are at different maturity levels with regard to long-term care policy and the organisational framework. Some Member States currently allocate relatively low levels of expenditure to long-term care, which might be indicative of long-term care being a low policy priority or of a heavy reliance on informal care (sometimes expressed as a legal obligation for family members to take care of their dependent relatives). Few Member States have long responded to the need to address long-term care as an important social risk by mitigating individual needs either through universal or at least partial coverage and public support in cash or in-kind. In these countries, long-term care is integrated into social security systems (next to health, accident/disability, retirement and unemployment) and/or an important part of social assistance schemes. 3.1.1.Organisation of long-term care systems Long-term care is organised in an often complex system of services across health and social care and sometimes other types of support, such as housing and local activities (e.g. volunteering). According to a recent report by the ESPN, only 10 out of 27 Member States (AT, BE, DE, DK, ES, FI, FR, LU, NL, SE) have an ‘integrated’ public system, (i.e. having a dedicated public social protection branch for long-term care) while out of these 10 countries, at least two feature either not totally integrated systems (AT) or a division of responsibilities among subnational levels (BE). The other 17 Member States have a public system usually split between social care/social assistance and healthcare and between authorities in charge of providing cash benefits and authorities in charge of providing in-kind services. There are differences in terms of the territorial level at which long-term care is organised. In most of the Member States (AT, DE, LU, NL, IE, MT, CY), the national level plays a pivotal role in the organisation of long-term care. Here, an important complementary role is played by local and regional authorities running services. Belgium, being a federal state, is a specific case where long-term care organisation has been mostly devolved to the regions (federated entities). In France, regional administrations implement national health policies defined centrally by the government, whereas the decentralised local authorities are responsible for social policy. In the Nordic countries (DK, FI, and SE) municipalities are in charge of ensuring an integrated healthcare and social care long-term care system. In 15 Member States (BG, CZ, EE, EL, ES, HR, IT, LV, LT, HU, PL, PT, RO, SI, SK), long-term care organisation responsibilities are allocated to different layers of government depending on the type of provision (healthcare services, social care services, and cash allowances). This horizontal fragmentation between the healthcare and social care systems, as well as the vertical fragmentation between the national, regional, and local levels implies different organisational structures and conditions of services not only across, but also within different Member States. As a consequence, the comparability of administrative data are limited, and sometimes data are even not available at national level. Formal long-term care services are organised as home, community-based or residential care. Home care means long-term care provided in the recipient’s private home, by professional long-term care workers. Community-based care means long-term care provided and organised at community level, for example, in the form of adult day services or respite care (semi-residential care), meaning that people in need of long-term care continue to live in their private homes but receive long-term care services outside of their home in a building within their community. By comparison, residential care is provided to people staying in a residential long-term care setting. In practice, these services are available in all Member States, alongside other in-kind contributions (e.g. house adaptations) or technological devices, but to a different extent. Home care is for example the main setting in a number of Member States (AT, CZ, DE, EE, EL, FI, IT, SE), while in others (FR, RO) most recipients of formal care are cared for in a residential care setting. Long-term care services provided by the national and/ or local authorities and associations are primarily considered as social services of general interest, as they have a clear social function: facilitate social inclusion and safeguard fundamental rights of older people; complement and support the role of families in caring for the oldest members of the society; provide assistance for people in permanent or temporal need etc. Member States provide long-term care services in-kind and via cash benefits. An important distinction among these schemes is between ‘bound’ cash benefits (beneficiaries have to document how the resources that they received are spent) or ‘unbound’ benefits (beneficiaries are free to use the resources as they prefer without any form of accountability). Most countries with cash benefits (12 out of 19) use ‘unbound’ cash benefits (AT, BE, BG, CY, CZ, DE, FI, HR, IT, PL, PT, SI). Only 7 (ES, FR, LT, LU, LV, NL, SK) use ‘bound’ ones. Schemes based on ‘bound’ cash benefits usually ensure coordination between the beneficiary and the long-term care public system (in terms of social workers and health professionals’ supervision, and in terms of integration with the provision of long-term care services). Schemes based on ‘unbound’ cash benefits leave more freedom of choice and flexibility to beneficiaries, but they do not often foster coordination and there is less leverage for public intervention for quality assurance of the care received.

Across the EU, significant differences exist also in the market structure for long-term care services. A recent study covering 16 Member States showed significant changes in the supply structure with more market-based provision through private actors (both for-profit and non-profit) over the last three decades in the countries studied. The quantitative data from five countries showed a trend towards privatisation in the market, with an increasing number of private for-profit and private non-profit providers – for example, in Italy (residential and semi-residential care), Germany (residential, home, and semi-residential care), Romania (residential care), Belgium (residential care), and Ireland (residential care and homecare). Marketization and privatisation can affect different dimensions of long-term care, including the supply and affordability of care as well as the quality of care provided and working conditions for care workers. Whereas formal care provision was initially offered or organised mainly by public authorities, and sometimes also by non-profit institutions and organisations, in some Member States (e.g. SE) private for-profit institutions have developed as a result of policies to increase freedom of choice in long-term care provision. At the same time, for-profit providers have also emerged or increased their presence in other Member States, even in the absence of similar policies. Altogether, different forms of long-term care provision co-exist in the Member States: these include public providers, private providers (both for-profit and not-for-profit), and informal care providers – with the share of each of these forms differing widely across Member States. Also, the shares of residential care, community care, and home care in the long-term care market differ significantly between the Member States analysed. Long-term care stakeholders are manifold. They include people in need of long-term care, their family members and organisations representing them, relevant authorities (national, regional, local), social partners, civil society organisations, social economy actors, providers of different long-term services (residential, home care, community-based care) and with various legal status (public, private for-profit, private non-profit), as well as bodies responsible for promoting social inclusion and integration and protection of fundamental rights, including national equality bodies. 3.1.2.Public expenditure on long-term care Population ageing will significantly increase demand for long-term care over the next decades. On average in the EU, public expenditure on long-term care is projected to increase from 1.7 % of GDP in 2019 to 1.9 % in 2030 and 2.5 % of GDP in 2050, with marked variations across the Member States (AWG reference scenario). The projections in this reference scenario are based on the assumption that there is no policy change in relation to the current long-term care systems in Member States and that half of the projected gains in life expectancy are spent without disability (i.e. not demanding care). Figure 3 shows the current (2019) public spending on long-term care as a share of GDP and corresponding projections for 2030 and 2050 based on the latest EU Ageing Report. An alternative ‘risk scenario’ additionally assumes an extension of formal care in a number of Member States, implying a doubling of expenditure on average in the EU‑27 by 2050. Building on the AWG reference scenario, the scenario is based on the additional assumption that the unit costs of long-term care and the social protection coverage for long-term care will converge upwards to the current EU average, incorporating the effects of such possible key policy changes. The increase in public expenditure on long-term care is therefore projected to be more pronounced with public long-term care expenditure increasing from 1.7 % in 2019 to 2.1 % in 2030 and 3.3 % of GDP in 2050 for the EU-27 as a whole. Figure 3: Public spending on long-term care as % of GDP, current and projections Source: 2021 Ageing Report (European Commission and EPC, 2021); base data for 2019. Out of total current public long-term care expenditure in the EU-27 in 2019, 26 % went on cash benefits, 26 % on home care, and 48 % on ‑residential care, with marked variations from these averages across the Member States. Typically, the average cost of residential care per person is higher than in home care, but that is also influenced by the fact that the population in residential care has a greater degree of dependency. Higher levels of public long-term care expenditure also translate into better social protection coverage for long-term care and access to long-term care services in general. Nevertheless, public expenditure needs to be fiscally sustainable to ensure the ability of a government to sustain its current spending, tax and other policies in the long run. Moreover, also the wider macroeconomic policies, such as fiscal, monetary and trade policies, shape long-term care in the context of women’s and men’s opportunities in paid employment and the resources available for policies aimed at reducing gender inequalities. 3.1.3.Financing long-term care Long-term care is either financed by public expenditure, which can be tax-based or social insurance-based social protection, or via private expenditure, which includes compulsory and voluntary private insurance schemes and out-of-pocket payments. However, in most cases, long-term care is financed through a mix of public and private sources. Data regarding the financing sources of long-term care is only partial, as many Member States report expenditure on the category long-term care (health) in the System of Health Accounts, but no data for the category long-term care (social). As it can be seen in Figure 4 , taxation rather than social insurance is the predominant form of public financing of long-term care in the EU (for 12 MS), while a number of Member States mix social insurance schemes with tax-financing (10 MS) and five Member States use predominantly compulsory social contributions. The specific design usually is grounded in the historical and institutional context of the Member State. Social insurance systems are financed from contributions, generally from employees and employers in the form of payroll taxes. A main advantage of social insurance-based systems is that funds are ear-marked for long-term care and the contributions give a person the entitlement to receive long-term care when they need it, thus likely increasing residents’ willingness to finance long-term care. With their contributions, the public expects clear eligibility criteria and a right to a level of benefits that is not means tested. At the same time, caps on the contribution basis (income thresholds above which no contributions are paid), and the focus on labour income, limit the redistributive effects within cohorts and are sensitive to changes in the labour market and the wage share of national income. Childless contributors may be required to pay a top-up on their contribution rate (e.g. DE), thereby introducing redistributive effects between people with and without children. However, also social insurance systems incorporate either user charges or the benefit rates are not necessarily sufficient to fund the full care package a person requires. In tax-financed systems, the costs of long-term care are met out of the general revenues from taxes levied on a national, regional or local level. These taxes can include taxes on labour, consumption, capital, etc. and it is the discrete and flexible choice of governments how much funds to allocate to long-term care. The broad tax base is often cited as one of the main advantages, as funding is not solely generated from labour income (wages) as is usually the case for social insurance, but also relies on capital income (e.g. capital gains), thus spreading the cost across production factors and mitigating fluctuations in the labour market. A well-diversified taxation system thus implies a lower cost on labour compared with insurance-based systems, supporting employment and growth. It can be distinguished between universal tax-funded systems and safety net tax-funded systems. Nordic countries (e.g. SE, DK, FI) are typical examples of universal tax-funded long-term care systems with generous coverage and low out-of-pocket payments. Nordic long-term care systems are usually decentralised and municipalities and local governments have some autonomy in determining the needs assessment and eligibility criteria and providing long-term care services. By contrast, safety net tax-funded systems provide long-term care services only based on assessment of care needs and an assessment of the person’s (and sometimes their family’s) income and assets. Thus, publicly funded long-term care is prioritised to those with the highest care needs and with less income and assets. The principle aim of the means-test is to protect those individuals who would otherwise be unable to pay for long-term care themselves and would have unmet needs for care. However, such systems may result in increasing unmet needs if the threshold is set to low that the lower middle class is not poor enough to be eligible but nevertheless struggle with care expenses. Private long-term care insurance can take the form of either compulsory or voluntary schemes. Compulsory private insurance exists mainly as a substitute for social health insurance in countries where some population groups can opt out of public insurance if they obtain private coverage instead (e.g. DE). Voluntary private insurance generally complements existing coverage from a publicly financed benefit package, but play only a limited role in a number of Member States (e.g. AT, DE, FR), except for Cyprus, where voluntary insurance schemes for long-term care account for 26.4 % of expenditure. Practically all EU Member States apply some form of cost-sharing or fees. The very few countries with safety net schemes that do not rely on fees, have high means testing thresholds that limit the beneficiaries’ access to the public long-term care system. Compared to the risk sharing approach of the other financing sources, out-of-pocket payments do not feature any pre-payment and funds are not pooled across the population. Figure 4 shows that the share of reported out-of-pocket payments for health-related long-term care expenditure ranges from 77 % in Bulgaria to 0.2 % in Czechia. The unweighted average of absolute out-of-pocket health long-term care expenditure in the EU is equal to 0.1% of GDP. However, there are six EU countries where this value is equal to at least 0.3% of GDP (AT, DE, ET, FI, FR, MT). The OECD (section 3.2.3) analyses to what extent people in need of long-term care would be able to pay the out-of-pocket costs of long-term care, as the costs of long-term care in many cases exceed a person’s income. The minor role voluntary private insurance schemes play in Europe may reflect the fact that the costs of voluntary private insurance are very high, while it usually provides only limited coverage. Technical problems, largely in terms of information for both providers and potential buyers, suggest that the actuarial mechanism is not well suited to addressing risks associated with developing long-term care needs. These include problems of adverse selection, in particular when people buy premiums later in life; and the fact that people may not adequately plan for the risk of long-term care in old age, leaving it too late to take out voluntary private insurance. At the same time, the existence of minimum provisions for long-term care via public funding may reduce incentives for people to invest in voluntary insurance. In addition, private long-term care insurance policies may be regressive in that the premiums may not be affordable to all across the income distribution. The premiums are typically based on a person’s age and risk profile rather than income (as is the case of social insurance), limiting redistributive effects. Because of inherent difficulties in calculating a premium that is reasonable based on what the long-term expenditure could be on an aggregate level in 30 years’ time, voluntary private insurance usually pays a monthly compensation for long-term care needs, rather than covering the full care costs. In addition, the capital requirements may become prohibitive for insurers when mortality and morbidity rates are taken into account in long-term care insurance in some markets. Nonetheless, as even the most generous public long-term care systems impose some degree of cost-sharing or fall short of covering all long-term care needs, there may be a role for voluntary private long-term care insurance in supplementing them.

Figure 4: Share of expenditure by financing schemes for the health component of long-term care expenditure Source: Eurostat, SHA 2019, hlth_sha11_hchf, data for long-term care (health). No information available forMalta and EU-27; voluntary healthcare payment schemes for CZ, SK and SE; and rest of the world financing scheme for BE, BG, CY, CZ, ES, FI, FR, HR, IE, IT, LV, PT, RO, SE, SI, and SK (assumed as 0 in figure). 3.2.Social protection for long-term care Social protection coverage is an important factor for determining the affordability of long-term care services and ultimately access to long-term care. Although all Member States offer some social protection coverage for long-term care, in many Member States, financial constraints are the most important reason why households do not use (more) home care services if needs are present (see Figure 8 ). The generosity of social protection can play a key role in addressing such financial risks. At the same time, long-term care is less developed in many countries than other social protection branches (e.g. pensions and healthcare). Social protection for long-term care needs is highly fragmented among different branches of social protection, which are not always integrated with one another. In addition, public expenditure is often too limited to provide the services people would need. 3.2.1.Eligibility for social protection for long-term care Individual needs assessments form the basis for the provision of long-term care benefits and usually take into account the presence and extent of difficulties with ADLs/IADLs, along with cognitive and/or other limitations. The common denominator for standardised assessments in Member States is the measurement of dependency on help with ADLs and IADLs, sometimes weighting needs differently in the final assessment. Several Member States (e.g. BE, HU, MT) use rather quantitative overall assessments based on the degree of need of an individual, using a scale of point values and calculating a final score. Similarly, Germany uses a qualitative and individual-based assessment tool, translating the outcomes into a points scheme leading to a measure of the grade of an individual’s self-reliance and abilities. For example, needs for self-care account for 40 % of the overall assessment, while cognitive and communication skills account for 15 %. On the other hand, some Member States (CZ, EE, FR, LV) use more qualitative scales in assessing to what extent an individual is dependent or autonomous in daily activities. Estonia modified legislation in May 2022 that obliges local governments to identify/assess the need for support for a person with a care burden and liberates second degree relatives from the requirement to provide maintenance. In relation to the way they define eligibility to long-term care social protection, EU countries differ as to whether they adopt a universalist approach (characterised by high social protection coverage for all residents, and universal publicly provided services and benefits) or a selectivist one (characterised by targeting or customising services and policies for particular groups, usually safety net tax-funded systems). A ‘selectivist model is present in 10 Central-Eastern European and Southern European countries (BG, CY, EE, EL, HR, HU, PL, PT, RO, SI); in these countries, access to long-term care public provision, either cash benefits or in-kind services, is dependent not only on an assessment of care needs, but also on financial means testing (usually based on income, and in some cases property, often including close relatives’ economic resources). 3.2.2.Coverage of social protection for long-term care Member States provide long-term care services either in-kind or via cash benefits that enable the recipient to cover (part of) the costs of long-term care, or via a combination of both. In-kind services usually include home care or a place in residential care, but in some countries it may also cover other necessities such as adaptations of the home (e.g. lift) or technical devices (as part of home care). Cash benefits are funds that recipients can use to purchase services themselves, and are often used to compensate informal carers. Differences in the depth of social protection stem rather from the level of service coverage than from the different ways in which social protection is provided. In some (mostly Nordic) Member States, social protection is mostly delivered in the form of services (e.g. DK, FI, SE); in others, long-term care coverage is predominantly based on cash benefits (e.g. AT, CY, IE, IT, RO); and in yet others, beneficiaries have a choice between cash benefits, in-kind services, or a combination of the two (e.g. DE). The large majority of EU countries also offer cash benefits for carers, either through specific ad hoc programmes (DK, EE, HU, IE, MT), or by allowing informal carers to receive the cash benefit allocated to individuals with long-term care needs. Figure 5 shows that the estimated number of potential dependants aged 65 or over receiving publicly provided or funded home care varies between 132 % (NL) and 3 % (PT). The EU‑27 average stands at 31 %. By comparison, the EU‑27 average for publicly provided or funded residential care coverage is 19 %, and for cash benefits is 46 %. The lowest rate of public residential care coverage is 0.2 % (EL), and the highest is more than 39 % (LT, NL) for potential dependants aged 65 or over. Although several Member States do not provide cash benefits to finance long-term care needs, in Poland nearly 184 % of potential dependants aged 65 or over receive them. The fragmentation of long-term care systems, implying different organisational structures and conditions of services in different Member States, limits the comparability of corresponding administrative data (for instance, some Member States may focus more on specific care settings than others) and will lead to some double-counting if the coverage of the three different care settings is aggregated without adjustment. Some Member States that indicate a high coverage of the population with long-term care benefits may only provide benefits at a low level and they may not be targeted specifically to people with long-term care needs. In the case of Poland, for example, a cash allowance is paid to all people above the age of 75 independently of their disability status. Therefore, it is important to also consider the generosity of the long-term care benefits (see section 3.2.3). Figure 5: Share of potential dependants aged 65+ who receive public care or cash benefits Note: Coverage rates in the base year of 2019. Coverage estimated as ratio between recipients aged 65+ and potential dependants aged 65+. Recipient data provided by Member States. Coverage may be above 100 %, as the EU-SILC variable used to define dependency status focuses on (self-reported) ‘severe’ limitations only, whereas some social protection systems may also provide coverage for less severe needs, such as people who need help with IADLs: this biases the estimation of coverage upwards as it under-estimates the dependent population. In addition, adding the coverage across settings would in many cases yield coverage rates above 100 %, as some recipients may receive cash benefits and in-kind benefits at the same time. The population of potential dependants based on the 2015-2018 average of EU-SILC data on ‘self-perceived long-standing limitation in activities because of health problems [for at least the last 6 months]’ is used and adjusted for the number of people living in residential homes. For Germany, coverage refers to the social insurance funds’ members only. Source: 2021 Ageing Report (European Commission and EPC, 2021), for potential dependants aged 65+. The European Social Policy Network (ESPN) analysed Member States’ long-term care systems and proposed an analytical framework with a typology of public long-term care models in the EU. Interestingly, each model includes countries adopting different sources of funding. The choice of how to finance public long-term care systems seems almost independent from the choice of how much to spend and on which type of provision. The six identified models are: 1.A limited State intervention model: one third of all EU Member States falls under this category, which is characterised by a very low level of public expenditure on long-term care (on average 0.4% of GDP). The countries belonging to the cluster are exclusively either Southern European (CY, EL, PT) or Central-Eastern European countries (BG, EE, HR, HU, LV, RO). 2.A mild State intervention through cash benefits model: around one fifth of EU Member States belong to this second model, where public expenditure on long-term care is higher than in the previous one (on average 0.8% of GDP), and almost half of this expenditure is channelled through cash benefits (46.0%); Spain and four Central-Eastern European countries (LT, PL, SI, SK) belong to this cluster. 3.A mild State intervention through services model: around one Member State out of ten belongs to this cluster, where countries invest more resources in long-term care than the previous models but still below the EU-27 average level; at the same time, funding goes essentially to home care and residential care services; (IE, LU, MT).

4.A strong State intervention through cash benefits model: Austria, Germany, Italy and Czechia share a model where financial support for long-term care needs is relatively consistent (1.7% of GDP), and often takes the form of cash transfers. 5.A strong State intervention through services model: Belgium, France, and Finland spend a relatively high share of their GDP on long-term care policies (2.0% of GDP), using mostly services as a tool of provision. 6.A very strong State intervention through services model: two Nordic countries (DK and SE), together with the Netherlands, are part of this last group investing a very high share of public resources in coverage of long-term care needs (3.5% of GDP), and mostly counting on in-kind provision in order to support individuals and households. ESPN analysis indicated that the limited State intervention model has the weakest performance: it provides the lowest coverage rate of long-term care needs and has a very high share of older people with severe activity limitation who are at risk of poverty and social exclusion. The model based on mild State intervention through cash benefits offers a higher coverage of potential beneficiaries than the previous model, but at the same time, being an older person with severe activity limitation is still a strong predictor of poverty or social exclusion compared to not having activity limitation. The mild State intervention through services and the strong State intervention through services models provide a high coverage of potential beneficiaries through services. At the same time, they help to strongly reduce the impact of activity limitation on the risk of poverty and social exclusion. The model based on strong State intervention through cash benefits covers a large part of potential beneficiaries, more often through cash transfers rather than through services. At the same time, it produces relatively good results in terms of reducing the risk of those with strong activity limitation being poor or socially excluded. The very strong state intervention through services model covers practically all potential beneficiaries, and can intervene and provide services also to individuals with medium-low levels of long-term care needs. At the same time, it helps to strongly reduce the impact of activity limitation on the risk of poverty and social exclusion. 3.2.3.Adequacy of social protection for long-term care To measure the depth of social protection for long-term care in old age and compare it across Member States, with the support of the European Commission, the OECD developed a set of eight typical cases of long-term care needs. The cases vary according to the types and severity of their needs, the professional services required, and the level of income and assets of older people in need of care. The OECD analysis reveals that without social protection, the estimated total costs of long-term care often exceed the disposable income of people in need of long-term care and can push individuals into poverty. Furthermore, it suggests that even after social protection, the out-of-pocket costs for care can be very high especially for older people with severe long-term care needs receiving home care. It is assumed that all eligible people take up social protection for long-term care and that long-term care services are also available to them. Across countries and subnational areas, out-of-pocket spending as share of income is lowest for low needs and highest for severe needs. Figure 6 shows that the out-of-pocket costs of home care for low and moderate needs are lower than the median income among older people in 19 countries or subnational areas. Out-of-pocket spending on home care generally represents less than 50% of the median income among older people with low needs, and in a majority of countries and subnational areas out-of-pocket costs are lower than disposable incomes. In seven countries or subnational areas (HU, South Tyrol in IT, FR, SI, HR, LV and Tallinn in EE) the out-of-pocket costs of home care for severe needs are higher than the income for an older person earning a median income. In these cases, care recipients may have to turn to family members, friends and others for financial support or informal care as a way to receive long-term care, or they will have unmet care needs. Figure 6: Out-of-pocket costs of home care as a share of income (after public support), for care recipients with a median income and with no net wealth, by severity level Source: OECD analyses based on the OECD long-term care social protection questionnaire, the OECD Income Distribution Database and the OECD Wealth Distribution Database It is important to consider whether existing social protection systems for long-term care could guarantee that no older person is at an increased risk of poverty due to developing long-term care needs. While people may be able to pay for care, it is often that they cannot afford care without going below a certain level of income. This remaining income is needed to cover all other normal expenses of life, like housing, food, clothing, transport, etc. In a next step of the project, the theoretical typical cases were matched with responses from the SHARE and TILDA surveys (waves 7 and 3 respectively), thus estimating the size of the group that would fall into the different typical cases across the 20 Member States, and also making it possible to determinate their socio-economic characteristics. Whether social protection can prevent people from being at an increased risk of poverty due to developing long-term care needs, can be analysed by comparing the observed risk of poverty among older people with a hypothetical measure of the risk of poverty if all older people estimated to have long-term care needs received public support. This comparison gives an indication of the hypothetical impact on poverty risks if everyone who is estimated to have long-term care needs sought formal care and had access to public social protection. It should not be seen as reflecting the actual impact of long-term care provided through public social protection systems on poverty rates in countries today, as many older people with long-term care needs do not receive formal care. Across the 20 jurisdictions assessed, in 15 jurisdictions a majority (50% or more) of older people with low needs would not be able to afford home care from their income alone without social protection (i.e. they would be at risk of poverty), in all 20 jurisdictions a majority with moderate or severe needs would be in this position for home care. If it were not for public social protection for long-term care in old age, the majority of older people in the EU jurisdictions analysed would thus not be able to pay the out-of-pocket costs of care from their incomes alone without being at risk of poverty. Even with social protection, the estimated share of people facing a relative risk of poverty in many EU jurisdictions is still higher for those with long-term care needs than in the older population in general. Figure 7 shows the poverty risk associated with long-term care for people with a median income and moderate needs. Figure 7: Share of the old age population that would be at risk of poverty after paying for the out-of-pocket costs of home care for moderate needs Source: OECD analyses based on the OECD Long-Term Care social protection questionnaire, the OECD Income Distribution Database and the OECD Wealth Distribution Database 3.3.Availability and accessibility of long-term care Long-term care services must not only be affordable, but also available and accessible for people in need of long-term care. However, the availability of formal long-term care services still differs greatly among Member States and the variety of long-term care options is often insufficient, despite formal long-term care becoming even more important in the future due to population ageing and changing family structures. More person-centred care options, such as home care and community-based care, have started to expand, though not evenly, across the EU. Furthermore, persons with disabilities, who represent a large proportion of those in need of long-term care, are also confronted with accessibility challenges. 3.3.1.Availability of long-term care services

The availability of long-term care refers to the relationship between volume and types of services and resources that are offered by the system and users’ needs. Already now the supply of formal care services is restricted due to both financial constraints and workforce shortages. Within the formal provision, there is a diversity of models for the delivery of care services, combining to different extents home care, community-based care and residential care. Although home care services were used by on average 28.6 % of people aged 65 or over living in private households who needed long-term care (at least one severe difficulty in ADLs or IADLs), the share ranged from 4.7 % in Romania to 53.7 % in Belgium in 2019. Among the respective populations with long-term care needs, slightly more women than men used home care services (29.9 % vs 25.7 %). The use of home care services is also influenced by household composition. Although 37.2 % of older people with long-term care needs living alone used home care, only 22.4 % of people living with others did so. Furthermore, there was a regional dimension in the coverage by home care services. In cities, 29.7 % of older people in need used home care services, compared with 28.7 % in towns and suburbs, and only 26.4 % in rural areas. Coverage by home care services fell slightly during 2014-2019, from 29.8 % to 28.6 %. Data on residential care infrastructure suggest very heterogeneous availability across the EU. The number of long-term care beds per 100 000 residents of all ages ranged from 27.4 in Bulgaria to 1378.4 in the Netherlands in 2019, underlining the fact that some Member States have a highly developed residential long-term care sector for older people. In some other Member States, residential care facilities are historically underdeveloped, while in yet others the supply of residential care has been reduced as a result of deinstitutionalisation policies. But even when residential care infrastructure exists, it often operates at limited capacity due to staff shortages. In Austria, for example, thousands of long-term care beds in particular in more rural areas cannot be filled due to staff shortages and relatives report difficulties to organise residential care for people in need. Differences between countries in care provision and care use are also affected by institutional and cultural factors. The willingness to use care, particularly institutional is influenced by cultural reasons and attitudes. In southern and some eastern European countries, for example, family relationships are closer than in western or northern countries, social protection is not as well developed and an expectation towards being cared for by family is expressed. People in need of care mainly do not use professional long-term care services because they are unaffordable or unavailable. Figure 8 shows that for 35.7% of households with a person in need of long-term care, the costs of the services where the main reason for not using (more of) them although they would require (more) assistance; 9.7% mentioned shortages in supply and 2.1% cited quality concerns as main reasons across the EU-27. Besides, the lack of care services is more pronounced in towns and suburbs (12.3%) and rural areas (10.4%) compared to cities (7.4%). Also, in rural areas professional care is more often refused by the person needing them (5.9%) than in cities or in towns and suburbs (4.6%). If formal care services are not needed or refused by the person needing them, it is implying that the care tasks are taken over by informal carers or that people have an unmet need for care. In the 2019 data, 46.6% of people aged 65 or over with severe difficulties in personal care or household activities reported that they had an unmet need for help in those activities. This lack of help was more pronounced for older women (47.7 %) than for older men (44.2 %) , and for the lowest income quintile (51.2 %) compared with the highest (39.9 %). Figure 8: Main reasons for not using (more) professional home care services Source: EU-SILC ad hoc module, 2016, ilc_ats15. 3.3.2.Accessibility of long-term care services Accessibility to long-term care refers to the prevention and removal of barriers that people with disabilities face to participate and access such services on equal basis with others. It concerns the design of products/devices, services, and infrastructure so that they can be used by people with disabilities, regardless their age, on an equal basis with others. Accessibility concerns the buildings where the services are provided, the transport from home to the delivery place and the information and communication about the services. The lack or limited accessibility of long-term care services prevent people with disabilities from using long-term care services. Further, objective barriers and subjective motives can prevent people with disabilities from accessing long-term care. The geographical distance and travel costs in case the place of service provision is not the care user’s home may be prohibitive. Waiting time for the initial long-term care needs assessment by the competent authorities or between the initial contact between service provider and user and the date of actual service is also an element that can limit accessibility. The overly complex application procedure for benefits may be disproportionate with the time and ability of people in need of care to cope with this. Besides, people may lack awareness of, or have misperceptions about, eligibility or application procedures. Stigma as well as a desire to protect their privacy may play also a role. While there is no EU-wide data on the accessibility of long-term care services in the EU, anecdotal evidence suggests that people with disabilities can face obstacles. 3.4.Quality of long-term care Member States employ a mix of policies and practices to improve the quality of long-term care, but long-term care quality standards and their assurance mechanisms are often weak. A few have quality frameworks dedicated specifically to long-term care, setting out the quality principles that long-term care services should fulfil. More often, minimum standards and requirements usually operate through registration and accreditation processes. Among different approaches, the person-centred model, based on the needs and preferences of the person in need of care, seems to be gaining attention. Quality of care is also affected by factors that include workforce, organisation (e.g. integration of services to cater for complex needs), technology, and funding. The efforts to ensure quality are mixed and mainly focus on residential care, thus more attention is needed also on home and community-based care. 3.4.1.Defining the quality of long-term care For people receiving long-term care, its quality is critically important, and in some cases can be the difference between life and death. For society as a whole, the quality of long-term care services, determines its ability to uphold fundamental rights and dignity. Quality long-term care can improve as much as possible and/or prevent the deterioration of physical and mental condition of people in need of care, enable their independent living and personal well-being, safeguard their dignity and protect them from harm and abuse. Better quality care can help avoid unnecessary hospital or residential care admissions or can slow down the deterioration of physical condition, thus potentially alleviating the pressure on resources. There is no common definition of long-term care quality at the EU level, but breaking down the concept of quality into a number of principles helps to build a more comprehensive picture and to better target policy tools. The principles of the voluntary European Quality Framework for Social Services agreed in 2010 apply to long-term care services, in particular the principles of prevention, respect, person-centredness, comprehensiveness, continuity and transparency (see section 5.3.2 for more on quality principles). As quality is multifaceted, it is difficult to define indicators to measure and monitor it. One way to operationalise the concept is by looking at the structure, process and outcomes. ‘Structure’ refers to inputs and resources, e.g. physical facilities, equipment, human resources, including training, working conditions and pay. ‘Process’ is the way care is delivered, e.g. diagnosis, treatment, preventive care, patient education, obtaining information from medical records, interviews with patients and doctors, or direct observations. ‘Outcomes’ are the effects of care on patients, e.g. changes to their health status or functionality. There is an emerging consensus that there is a need to measure quality based not only on clinical indicators, but also by taking a person-centred perspective and including measurements of the users’ quality of life. This is in line with the shift to a more holistic view in which older people’s well-being and quality of life and their preferences regarding care and support are central to the design of services in line with existing human rights standards. The latter include the rights of people with care needs, including people with disabilities, to live independently and be included in the community, with choices equal to others, to have the opportunity to choose their place of residence and where and with whom they live on an equal basis with others and not to be obliged to live in a particular living arrangement. Independent living applies equally to private and residential homes. It requires a differentiated landscape of quality, accessible, person-centred and affordable, community- and family-based services to allow people in need of long-term care to have control over their daily lives, in particular those living in residential care homes. However, the situation is particularly difficult in remote and rural areas and the COVID-19 pandemic highlighted and intensified the challenges faced by people living in institutions. 3.4.2.Quality assurance in long-term care Quality assurance practices vary between and within Member States due to various factors, including quality assurance mechanisms themselves, which may be different at national, regional and local levels, the nature of quality standards and how they apply to different types of care providers, whether public, private for-profit or non-profit. Quality assurance in long-term care is a point of debate in a number of countries, including due to a string of cases of poor care and mistreatment. This has caused substantial debate over how quality can be better assured and monitored in both public and private care settings. A EUROFOUND report highlighted few challenges linked to expansion of private provision increases, indicating that costs to users are likely to become a more significant issue unless there is an increase in public benefits to subsidise funding. There are also differences in the location of different types of care homes, with private care homes more likely to be found in affluent urban areas. The types of residents prevalent in each type of care home are influenced by the profitability of the services they require – residents who require less profitable care services are more likely to be in public care homes. In most countries where information about staff-to-resident ratios was available, there were more staff per resident in public care homes.

The main elements of long-term care quality assurance systems, namely the setting and monitoring of quality standards, improving current practice and involving relevant stakeholders, are briefly discussed below. Although countries have different approaches to quality assurance in long-term care, the most common approach is establishing mandatory quality standards as well as monitoring procedures and enforcement or remedy measures to ensure that providers comply with them. Quality standards usually address the structural features and can refer to input / physical environment (e.g. fire and safety concerns, room size, common space available, number, training and education of staff caring for recipients), process of care (e.g. documenting the frequency with which staff apply creams and/or turn bed-bound resident to prevent pressure ulcers), and outcomes to which providers should aspire, most often clinical (e.g. occurrence of skin pressure ulcers or uncontrolled pain). Regulation of residential care is more common than regulation of home and community-based care. At the same time, key criticism of residential care quality standards is that they are too ‘medical’, rigid, not evidence-based and do not measure what is important, which is now increasingly understood as the quality of life of the person receiving care. The next step in the regulatory process is the authorisation and accreditation of provider organisations. Authorisation usually confers the right to operate a facility or service, while accreditation also entitles providers to receive public funding. Both procedures are usually linked, and quality is assessed before a service is delivered. For instance, in DE, where only accredited providers can offer their services on the market, this procedure has been delegated to the regional branches of the long-term care insurers. In other Member States such agreements are linked to distinct accreditation or licensing procedures and may be administered at one of different levels: national (MT), regional (e.g. AT, IT) or municipal (e.g. DK, SE). Regional instead of national authorisation may lead to regional variations of quality, both in the definition of standards and regarding the implementation of quality assurance procedures. There are also variations in terms of requirements and standards applied to different care settings, with such standards being more developed for residential rather than for home-based care settings. Following the initial assessment of compliance with quality standards, the next step is to aim to monitor and constantly improve results. This could be done through follow-up to proposals for improvement resulting from systematic self-assessment of long-term care providers and/or inspections and/or reviews by third party that has been employed to certify the organisation’s quality management system. The design of enforcement systems needs to be carefully considered. While shortcomings and errors must be identified to be overcome and addressed, enforcement measures and penalties could also reduce the resources of already ‘low performing’ organisations, thus leading to even lower performance and further harming care recipients. Still, while enforcement of measures is necessary to sanction abuses and they therefore exist in most countries (e.g. AT, BE, BG, DE, FI, MT, PT, RO, SE), economic incentives for quality improvement and collaborative approach (inspectors working with providers to solve problems) should be further fostered, to increase ownership towards continuous improvement of quality. In addition to a strict regulatory approach to quality assurance, there are different mechanisms that allow relevant stakeholders, first of all people receiving care and their family members, to have a say on quality of care. Complaint mechanisms for users and their families are widely established instruments at organisational level, though more developed in residential care settings. At national level, mechanisms are put in place at the level of the ombudsperson and now also of OPCAT commissions, albeit, and again, focusing on residential care. The OPCAT commissions are now in place in all Member States to combat the worst cases of non-compliance, namely abuse and neglect of residents in care homes. Mutual agreements among stakeholders, though not widespread, provide the opportunity to reflect upon mutual expectations and the involvement of the various stakeholders in existing care arrangements and individual care planning. At an organisational level, users can be involved via satisfaction surveys. However, these tools have their limits in long-term care, particularly when it comes to involving people with cognitive difficulties or simply because users might fear to say what think really think. A way out, though also limited, could be to have quality assessed by proxies (friends, family), but this also has its caveats as interests may sometimes diverge. 3.4.3.Drivers of quality Quality is affected by a number of factors, including funding, workforce and technology. Adequate funding is key to ensure long-term care quality, but even with limited public expenditure (see section 3.1.2), it is still possible to find ways to achieve better outcomes with resources at hand. Better targeting care to individual needs and involving all relevant stakeholders (including informal carers) and services (including healthcare) that cater for these needs in a coordinated way via integrated care provision and the expansion of case and care management could improve the efficiency of resources. Also, when long-term care services are commissioned or procured, including quality indicators and performance standards focusing on positive outcomes for people receiving care in public procurement contracts could help to move from fee-for service to outcome based financing . The availability and expertise of care workers has a major impact on the quality of care and the quality of life of those being cared for. This calls for policy measures to ensure adequate human resources for long-term care, including ensuring adequate staff ratio, providing quality management training for care managers and workers and involving care staff in the assessment, monitoring and improvement of care quality. Technology could help to improve care quality, including by making services more personalised and increasing users’ independence. However, beyond cost considerations and the acknowledgement that technology cannot replace human contact, there are challenges regarding insufficient availability, accessibility, reliability, and acceptance of new technologies as well as concerns about the protection of personal data. 3.5.Long-term care workforce and informal carers Carers are the backbone of long-term care systems. Meeting the rising demand for long-term care can support job growth, but Member States struggle to attract and retain care workers. Difficult working conditions and relatively low wages are drivers for labour shortages in the sector. Skills requirements in long-term care are becoming increasingly complex. Informal carers, mostly women, carry out the bulk of caregiving in many Member States. Informal caregiving often comes with significant consequences for the carers, including difficulties to reconcile work and caring responsibilities as well as consequences on health and wellbeing. 3.5.1.The long-term care workforce The long-term care workforce consists of a range of professions, most importantly personal care workers and nurses. In 2019, an overwhelming majority of 88% of long-term care workers were women in the EU. In 2019, the share of foreign-born long-term care workers (from within and outside the EU) was close to 20%. Most long-term care workers have a medium education level . Skills requirements in long-term care are becoming increasingly complex, including the need for case management, soft and digital skills as well as geriatric and special knowledge (e.g. Alzheimer, chronic diseases). Despite the relatively high rate of training (58% of long-term care workers received training paid for or provided by their employer, compared to 38% overall), 24% of long-term care workers felt that they ‘need further training to cope well with duties’ (15% overall) . Live-in carers are a particularly vulnerable subgroup of long-term care workers prevalent in a number of EU Member States (e.g. AT, CY, DE, EL, ES, IT, MT). In most cases, they are mobile (intra-EU mobile workers) or migrant workers. Undeclared work among live-in carers can be a common issue in some Member States. Live-in carers may face extremely low wages, sometimes not even receiving the applicable minimum wage in the country. Given that live-in carers usually live with the care recipient (who is sometimes but not always their employer) under the same roof, working time arrangements, including adequate rest periods, may be blurry and sometimes not compliant with labour law, while enforcement of rights of live-in carers may be limited due to limitations on inspecting private households in certain Member States. While data on this is still sparse, domestic work, including the provision of long-term care, is increasingly provided via online platforms, bringing along risks for the workers such as lack of security, guaranteed hours or minimum pay rates, constraints on collective bargaining and ratings and reviews to discipline workers. Undeclared work is a challenge in particular in care services that are part of the personal and household services sector. 2.1 million people are estimated to work undeclared in the personal and household services care sector (including both childcare and long-term care), which account for 34% of the overall workforce working in this sector. 3.5.2.Untapped job creation potential and labour shortages in the sector The long-term care sector already accounts for a substantial number of jobs in many Member States. In 2019, there were 6.3 million long-term care workers in the EU (3.2% of overall workforce). As shown in Figure 9 , the number of full-time equivalent long-term care workers per 100 people aged 65+ was 2.4 on average in the EU-27 in 2019. However, there were large differences across Member States from fewer than 0.2 long-term care workers per 100 people in Greece to 12.5 in Sweden. Figure 9: Number of (full-time equivalent) long-term care workers per 100 people aged 65+, 2019 Source: EU Labour Force Survey, 2019, in: Barslund, M., et al., 2021. The long-term care sector has an untapped job creation potential, driven in particular by population ageing. In order to keep the current level of long-term care provision, many countries will have to significantly expand the long-term care workforce in the coming decades. More than 1.6 million long-term care workers would have to be added by 2050 to keep long-term care coverage at the same level. Most Member States would have to increase the number of long-term care workers by more than 15% by 2030, and for eight countries the figure is 30% or more/. In a scenario, where Member States converge upwards in their number of long-term care workers per 100 people aged 65+ (reaching 5.6 workers by 2050), 150 000 long-term care workers would have to be added yearly for the next 30 years to the current long-term care workforce to keep service provision at 2019 level within the EU. This would amount to around 4.5 million additional long-term care workers by 2050.

However, many countries struggle to attract a sufficient number of workers into the long-term care sector. A large majority of Member States have reported significant numbers of unfilled vacancies, or have estimated expected staff shortages in the long-term care sector. More than one in six of the 24.3 million online job advertisements analysed by Skills OVATE in 2021concerns the long-term care occupations. Personal care workers were the most requested (39%), followed by nursing and midwifery associate professionals (33%) and nursing and midwifery professionals (28%). In 2020, nursing professionals, nursing associate professionals and home-based personal care workers were among the 19 occupations for which ‘high magnitude shortages’ were identified in a number of EU Member States. As a result of the difficult working conditions during the pandemic, labour shortages in the sector became even more severe (for more information see section 3.6). Low wages are a main reason for labour shortages in the sector. Analysis from Eurofound shows that on average in 2018, wages for social services workers (close to 70% of which worked in the long-term care sector) were 21% lower than the average national hourly earnings. The high prevalence of part-time work (42%) in the long-term care sector implies even lower monthly earnings for many. The wage difference was smallest in the Netherlands (96% of average earnings), Austria and Luxembourg (both 92%); three countries where almost 100% of long-term care workers are covered by social partner agreements. Across the EU, social dialogue plays a mixed role in the long-term care sector. Only in some Member States, close to 100 % of long-term care workers are covered by collective agreements (AT, BE, DK, ES, FR, LU, NL, SI), while in others social dialogue in the sector is almost absent (CZ, EL, PL). Difficult working conditions further contribute to the low attractiveness of the sector. Evening, night or weekend shifts are common in the long-term care sector, affecting working time quality. The large share of part-time work among the long-term care workforce (42%) is not always voluntary, as 30% of part-time long-term care workers in home care and 20% in residential care work part-time because they could not find a full-time job. A significant share of long-term care workers (33%) have been exposed to adverse social behaviour, including verbal abuse, unwanted sexual attention, threats, physical violence, humiliating behaviour, bullying, and sexual harassment (compared to 16% in the overall workforce). Challenging working conditions take their toll on the health of long-term care workers. In 2015, 37% of long-term care workers reported that their job had a negative effect on their health, compared with 25% among the overall workforce. 38% of long-term care workers believed they would not be able to continue doing their job until they were 60 years old (compared to 27% overall). Occupational health and safety risks for long-term care workers include in particular lifting and moving people and handling materials that can be infectious, but also psychosocial risks. Furthermore, lower staff ratios can cause a precarious burden of work, which puts employees under constant time pressure. A recent study analysing the occupational precariousness of nursing staff in nursing homes in Catalonia in Spain found also that staff in privately owned facilities suffer greater precariousness with the main reasons for the precariousness being low wages and temporality of contracts. 3.5.3.Informal carers Despite increased social and political acceptance of the need for the state to guarantee access to formal care services, informal carers continue to provide the largest bulk of care in the EU. In 2018, about a third of the EU adult population (around 100 million people) had caring responsibilities. The majority of them took care of children below 15 (84 %), for incapacitated relatives (12 %) or for both at the same time (4 %). On average around 52 million Europeans (14.4% of the population aged 18 to 74) provide informal long-term care to family members or friends on a weekly basis. When using full-time equivalents, informal carers account for close to 80% of care providers at EU level. Figure 10: Share of population 18-74 providing informal care, by gender Source: Van der Ende, M. et al., 2021. Informal care has strong implications for gender equality, as a majority of informal carers (59%) are women. Women also provide more hours of care (17 hours per week for women, compared to 14 hours for men). The majority of informal carers (54%) provide less than 10 hours of care per week, while 25% provide between 10 and 20 hours, 11% provide 20-40 hours and 10% provide more than 40 hours per week. 5.3 million people in the EU are intense informal carers, providing more than 40 hours per week, of which 3.8 million are women. A large share of people providing informal long-term care are also engaged in childcare for children under 18, thus facing a double care burden (71% of women and 79% of men providing informal long-term care). Fewer women (36%) than men (51%) who provide informal care use support from formal care services. Informal care has a large economic and societal value. Informal carers provide 33 to 39 billion hours of informal care per year. These hours can be associated with a certain value, applying different methods. When applying the proxy good method, the most likely value of these hours is 2.7% of EU GDP. When applying the opportunity cost method, their most likely value is 2.4% of EU GDP. Both methods reach a value that is much higher than current public expenditure on long-term care (1.7% of GDP in the EU). The majority of informal carers are employed, but labour market participation decreases with intensity of care provided. 64% of informal carers are employed, compared to 67% of the overall population aged 18-64. While 71% of informal carers providing less than 10 hours per week of care are employed, the employment rate of informal carers providing more than 40 hours per week is only 35%. Women, in particular in the age group 45-64, are more likely to drop out of the labour market as a result of caring responsibilities (their employment rate is 54% compared to 59% overall in this age group). Women with caring responsibilities in this age group who drop out of the labour market face on average an annual wage loss of EUR 18 000 net/. This is also later on translated into lower pensions, and more difficulties in affording the costs of long-term care, once the informal carers become themselves dependent on receiving care. Informal care is also associated with costs for society as a whole. Such costs include losses of tax and social security revenues due to informal carers’ lower labour market participation, and expenditure on allowances for carers. Care responsibilities are still predominantly borne by women, keeping 7.7 million women out of the labour market (compared to only 450,000 men) and contributing to the gender employment gap. Estimates conclude that public costs associated with informal care could amount to around 1 % of GDP, more than half of current public expenditure on long-term care (1.7% of GDP). 3.6.Impact of COVID-19 on long-term care systems Long-term care systems have been strongly affected by the COVID-19 crisis in view of their users’ high vulnerability to the virus and the impact on the carers. The pandemic has reinforced the already existing structural challenges regarding the availability, accessibility and quality of care as well as the situation of formal and informal carers. In general, the pandemic has disproportionately hit older people who are at a higher risk of developing severe disease and more likely to die due to COVID-19 because of being frail and having underlying medical conditions . Available cumulative data up to spring 2021 has shown that COVID-19 deaths of people aged 60+ (IE, LT, ES, IT, DE, FR, CZ, NL, PT, SE, DK) or 65+ (AT, BE, SI) represent at least 90% of total registered COVID-19 deaths. Around half of Member States (BE, DK, EE, FI, DE, EL, HU, LT, LV, NL, PT, ES, SE) had in place emergency guidelines on infection control in long-term care before the outburst of the COVID-19 crisis. Some EU countries (AT, FR, IE, IT, SI) had developed emergency preparedness systems for the healthcare sector in general, but not for the long-term care sector in particular. The ones with emergency preparedness, though, were not necessarily less affected by the COVID-19 crisis. The lack of collaboration and coordination between the health and social sectors was shed light on during the pandemic . Most of the nursing homes were not medically prepared to meet the challenges of the pandemic. Before the outbreak, only several Member States (CZ, DK, FI, FR, DE, FI, LU, PT, SI) had reported having guidelines or legislation on the integration of long-term care and primary care. The availability and accessibility of care have been impacted in different ways as a result the COVID-19 pandemic. More than half of the Member States limited access to long-term care services during the crisis . In order to reduce the risk of spreading COVID-19, day care centres were temporarily closed or made subject to limited access in a number of EU countries (CZ, DE, HR, HU, LU, NL, PL, RO, SI, SK), at least during the first wave of the pandemic. Similarly, access to home care was reduced in several Member States (FR, LU, NL, SI), while in others home care services were limited to strictly necessary visits (e.g. BE, CY, FR, NL). In Austria problems in home care arose especially regarding live-in care at home, who come mostly from central and Eastern Europe. Travel bans prevented carers from travelling between their place of work and their home in a usually biweekly cycle. Conversely, long-term care facilities continued to provide care in most Member States . However, in most EU countries residential care providers appeared to be largely unprepared for the epidemiological threat: insufficient sanitary procedures related to isolation of potentially infected people, shortages of personal protective equipment particularly in the social sector, staff shortages and insufficient testing . In cases of COVID-19 outbreaks, the most common response of long-term care facilities was to minimise contact from outside as much as possible and reduce in-person interactions inside . In several Member States (BG, EE, HR, LU, PL), the placement of new residents in residential care was temporarily restricted. As an attempt to offset the reduced availability and accessibility of care services during the pandemic , caregiving via telecommunication was strengthened. A number of countries have enhanced digital care provision (CY, ES, FR, NL, PL, RO). Nevertheless, informal care is likely to have compensated for a significant share of the care that was previously provided by professionals. In addition, anecdotal evidence suggests that people in need of long-term care sometimes chose to reduce or not to receive care in order to minimise their risk of contracting COVID-19. During the first months of the crisis, unmet long-term care needs may have increased. Reduction in the availability of formal care services due to the pandemic and social distancing have possibly enhanced the dependence on informal carers, implying an additional psychological and financial strain on them. A survey of Eurocarers shows that the pandemic led to more and new informal carers, as more than 10% of respondents started to provide care as a result of the pandemic. COVID-19 negatively impacted several aspects of many carers’ lives, including social network/participation (78.7%); quality of life (76.8%); mental health/psychological state of mind (66.5%); access to health/social services for the care recipient (59.8%); and care recipient’s health status (54%) . Informal care appeared to be taking a heavier toll on women, in comparison to men, in terms of increased intensity of the informal long-term care provided, decreased reliance on formal care services, or difficulties in reconciling work and care duties, to name just a few . In addition, evidence suggests that the share of people aged 50 or over who became unemployed, were laid off, or had to close their business because of COVID-19 by August 2020 was higher for informal carers than for non-informal carers in almost all EU countries .

Furthermore, the COVID-19 pandemic had a negative impact on the quality of care and the quality of life of people receiving care. In order to prevent the COVID-19 virus from spreading through care homes, external visits were banned, residents were often isolated from one another, and visits from carers were limited to attending to their basic needs . Only later, it was possible to alleviate some of the isolation and protection measures with an increase in testing and later in vaccination capacity across the EU. Special meeting areas were designed (DE), contacts with visitors were carried out using telephones or video tools (CY, BG, DE, FR, HR, HU, LU, SK) or, when visits were allowed, their rules were revised to make sure that visitors did not display COVID-19-related symptoms (DK, HR). Creative solutions were also deployed to help residents cope with isolation, such as ‘corridor-games’, music broadcasting, and entertainment events (FR, LU). The COVID-19 pandemic has also worsened the working conditions of long-term care workers . Long-term care workers have been more exposed to the virus and related potential health risks, compared to other professions. Evidence from some Member States has shown that long-term care workers have taken more days of sick leave during the pandemic than during comparable periods before (DE, LU, SI). Not only the physical, but also the mental health of long-term care workers was of concern during the pandemic. As a result of the difficult working conditions during the pandemic, labour shortages in the sector increased. Between 2020 and 2021, highly likely due to the pandemic, the published online job advertisements for long-term care occupations grew by 39%. According to a recent survey of the Federation of Social Employers among employers’ organisations and social service providers from 20 EU countries, a large majority of respondents faced staff shortages, which for most worsened over the course of 2021, as a result of the pandemic. The sub-sector most concerned was services for older people . To address the issue of staff shortages urgently during the COVID-19 crisis, a number of countries implemented some temporary changes in rules, regulations or laws. These included: relaxation of education requirements (CZ, DE, LT, NL, HU); short-term contracts with foreign workers (LU); bonus payments for long-term care workers (CZ, DE, PL, RO, SK) or live-in carers (AT); bans on firing for long-term care workers (ES); accelerated accreditation of foreign diplomas (DE, EL, LU, PT); mobilisation of workers from other sectors , including the healthcare sector (BE, DE, FR, HR, PL); and mobilising volunteers, medical students, and retirees (CZ, DE, IE, LU, PL, RO). Beyond the immediate effects of the COVID-19 crisis on long-term care systems, it is also important to consider the potential impact on the preferences for a specific long-term care setting after the pandemic . Some first evidence comes from Canada, which was hit by the pandemic in a similar fashion as EU Member States. The study has established that as a result of the pandemic residential care has become a less attractive long-term care option, as there has been a shift towards stronger preference for home care. This is likely to influence people’s saving behaviour as well as the type of policies they would support (e.g. citizens more likely to support home care subsidies financed by taxation). Moreover, a study commissioned by the European Parliament points out that research consistently reveals a preference for home-based care among older people, in addition to evidence that home-based care is less costly and has the potential to offer better quality care, compared to traditional institutionalised care. 4.Current Union support and the case for reinforced action at EU level While the design and organisation of long-term care is primarily a competence of the Member States (Article 153 TFEU), long-term care touches on several policy areas with relevance for the European Union legal acquis and initiatives (e.g. social inclusion, social protection, social security coordination, free movement of workers, working conditions, skills, healthcare, gender equality, fiscal sustainability, etc.). The European Pillar of Social Rights proclaimed in 2017 set out in its Principle 18 that ‘everyone has the right to affordable long-term care services of good quality, in particular home care and community-based services’. The Pillar principles also cover the carers’ perspective by highlighting a number of principles related to working conditions as well as the right to leave. As part of the European Pillar of Social Rights action plan that followed in 2021, the European Commission proposed to turn principle 18 on long-term care into concrete action via an initiative. The European Commission has been supporting the activities of the Member States at various levels by policy guidance, such as the Social Investment Package . Further, it has undertaken analytical work in this area, monitored long-term care-related developments and supported mutual learning and exchange of best practices in close cooperation with the Member States, civil society, and other stakeholders. This is achieved mainly through the Social Open Method of Coordination and the European Semester. Existing acquis are also touching upon different dimensions of long-term care policies. Funding for policy reforms and investments, social innovations and research are equally part of the EU support mobilised for long-term care. 4.1.EU initiatives relevant to long-term care To date, several EU legis