EN Official Journal of the European Union C 204/103

Opinion of the European Economic and Social Committee on Guaranteeing universal access to long-term care and the financial sustainability of long-term care systems for older people

(2008/C 204/21)

In a letter dated 19 September 2007 the future Slovenian Presidency asked the European Economic and Social Committee to draw up an opinion, under Article 262 of the Treaty establishing the European Community, on:

Guaranteeing universal access to long-term care and the financial sustainability of long-term care systems for older people (exploratory opinion).

The Section for Employment, Social Affairs and Citizenship, which was responsible for preparing the Committee's work on the subject, adopted its opinion on 21 February 2008. The rapporteur was Ms Klasnic.

At its 443rd plenary session, held on 12 and 13 March 2008 (meeting of 13 March), the European Economic and Social Committee adopted the following opinion, with 99 votes in favour and one abstention.

1. Conclusions and recommendations

1.1 Conclusions

1.1.1 Dependency on care is one of life's risks, the impact of which is difficult for an individual to bear alone and which therefore calls for an intergenerational solidarity-based shared responsibility (1).

1.1.2 The form which this responsibility takes must be decided mainly at national or regional level, taking account of different family and tax structures, employment situations, mobility, housing, population density, established traditions and attitudes.

1.1.3 As there are similarities in this area in relation to the problems facing the individual Member States as well as issues which transcend national boundaries, it is both right and necessary for the subject to be dealt with by the EU institutions. The exchange of experience, through the open method of coordination for example, has a particularly important role to play here, and in some cases legislative measures are also needed.

1.1.4 As in the health care system, the bulk of the costs of long-term care arise in the last years of a person's life. Since current social security systems (health care and pensions systems) were established, life expectancy has increased considerably. Facing up to the resulting new needs requires tackling difficult questions of intergenerational justice and solidarity, which require appropriate information and educational responses as well as policy measures (2).

1.1.5 The ultimate objective must be to make it possible for old and very old people in Europe to live their lives safely and with dignity, even if they are dependent on care, while at the same time ensuring that this does not impose unbearable burdens on the younger generations.

1.2 Recommendations

1.2.1 The European Economic and Social Committee calls on the European Council and the Commission, together with the Member States, to tackle the problems of an ageing population as a matter of urgency, in order to ensure that all older people receive the support and the quality of care that they need.

1.2.2 In order to do justice to the challenges of long-term care, a number of measures are needed. Some key aspects of this are the following: Financing and affordability — universal access to high-quality care must also be guaranteed in practice for people with particular problems or low incomes; — sustainable financing systems must be developed which do not leave individuals to face this risk alone, while also ensuring that society can afford such services without placing an undue burden on future generations; — the promotion of preventive measures should help to mitigate the rise in demand as far as possible. This will require a comprehensive preventive strategy bringing together aspects of health-related preventive measures, financial provision, social provision and measures to boost older people's ability to cope with everyday problems; — incentives — e.g. tax incentives — for private financial provision should be considered when it appears necessary to achieve the general interest objective of public health. Care and supply of services — the development of tailored care services geared to needs must also be ensured in regions which are currently disadvantaged in this respect; — existing family and neighbourhood networks, which currently provide the bulk of care, must be encouraged and strengthened, e.g. training of and support for family members; — NGOs, social economy initiatives and cooperative structures should be involved to a greater extent in care work; — special encouragement should be given to volunteering in the non-medical care sector, especially in the form of training for volunteers; — healthy competition between different suppliers of care services should give care recipients more freedom of choice and help develop the supply of services in accordance with defined quality standards, objectives, tasks, specifications and an established social security system, under the responsibility of the legislator in each Member State, since these services fall within the scope of social services of general interest (3); — older people and those in need of care must be included to a greater extent in social networks, inter alia in order to prevent abuse and ill-treatment; — best-practice models should be developed in palliative care in nursing homes and in home care; — hospice work should be developed. Care workers — the human resources must be provided for care services, in particular by providing high-quality training and improved working conditions for care workers and by upgrading the caring professions; — the recognition of qualifications throughout the EU should be facilitated; — the Commission is asked to review the arrangements for cross-border aspects of care, such as access to care services abroad and the migration of care workers; — in order to prevent work being performed in the black economy, measures must be adopted to bring hitherto illegally provided care services into the framework of a legal employment relationship, taking account of the specific features of work performed in private households. Care in the family — there should be greater incentives for providing non-medical care services, either within the family or on a voluntary basis (4); — strategies and services must be developed to address the problems of dementia and depression in older people, which are among the main challenges facing families and the care system; — it should be made easier to reconcile family and career through support and respite measures for working family carers (e.g. day-care facilities for older people in large companies, respite services, mobile care). Rules, standards and quality — quality standards should be developed for all areas of care of older people and effectively monitored by independent organisations or supervisory authorities and recognised by human rights institutions; — in this way it should also be ensured that human rights and dignity are protected in both public and private care homes and that the limited capacity to act and dependence on services of those in need of care are not used to their disadvantage. Use of information and communication technologies — the use of information and communication technologies, telematics and technical aids should be encouraged in care work and for monitoring purposes, with due attention to ethical issues.

2. Background

2.1 The Slovenian presidency hopes to carry on the Europe-wide debate on how to deal with demographic change, and will be placing particular emphasis on solidarity between the generations. The ratio between the younger, middle and older generations is changing. The proportion of older people continues to increase. In some places, today's young generation already accounts for only half the number of people born after the Second World War. These facts raise a number of new questions with regard to solidarity and co-existence between the generations. Today's way of life and division of labour, especially in the urban environment, hamper relations between the generations, weakening the ties between them and changing them significantly. There is a growing tendency to deal with the different generations separately, from the point of view of the rights they have acquired. The wrong kind of response here could even lead to conflict between the generations.

2.2 The Slovenian presidency intends to hold a conference (28/29 April 2008) on solidarity and co-existence between the generations, which will focus on: 1) solidarity between the generations on health care, family life and house building; 2) long-term care for older people.

2.3 In this connection, the Slovenian presidency has asked the European Economic and Social Committee to draw up an exploratory opinion on Guaranteeing universal access to long-term care and the financial sustainability of long-term care systems for older people.

3. Long-term care as a European challenge

3.1 Long-term care is one of the key social challenges facing all the countries of the European Union. It must therefore also have its place on the agenda of the European institutions.

3.2 The European institutions have — without prejudice to national competences — launched numerous initiatives (5) on the subject and have in particular promoted the reciprocal exchange of experience using the open method of coordination (6). These efforts should be continued and stepped up; in relation to the use of this method, the EESC attaches the highest importance to the involvement of the social partners and civil society players.

3.3 The reports drawn up by individual states in this connection show that, despite differing starting situations and conditions, many challenges are similar in most countries. A cooperative approach to seeking solutions would therefore make sense.

3.4 The objectives jointly agreed at EU level regarding universal access to services, high-quality services and sustainable financing of systems are also confirmed by these reports. These objectives are also the basis of this opinion.

4. The demographic and social background

4.1 The growing demands on the long-term care sector are the result of a number of trends, which compound the problem in a number of ways.

4.2 As a result of steadily increasing life expectancy the number of very old people (over 80) in our societies is rising sharply; their numbers are forecast to increase by 17.1 % between 2005 and 2010, and by 57 % between 2010 and 2030. Thus, by 2030, there will be almost 34.7 million people over 80 in Europe, compared with 18.8 million today. Whilst in 1975 the over-80s made up only 2.0 % of the total population in the EU states, in 2050 they will account for 11.8 % (7).

4.3 Despite the common trends there are strikingly sharp differences within and between the Member States. Thus, life expectancy in the EU Member States varies from 65.4 to 77.9 years for men and from 75.4 to 83.8 years for women.

4.4 At the same time increasing numbers of older people live alone, because family members have moved away or because they are widowed. Mobility, including cross-border mobility, which is promoted in other areas of European and national policy, poses additional challenges for the care sector.

4.5 As a result of the low birth rate (in 1960 almost all EU states were above the replacement fertility rate of 2.1, whereas in 2003 all the EU states were below it) not only will the potential for intergenerational support (relationship between those needing care and potential carers) — and thus the potential for family care — decline, but it will also become increasingly difficult to meet the demand for professional carers on the labour market. Moreover, this trend will exacerbate the problem of financing long-term care.

4.6 Another aspect of social and demographic change, the change in family structures and the higher employment rate of women, means that, whereas in the past many care services were provided by the family, especially by the women of the family, this will not be possible, or at least not on the same scale, in the future (8).

4.7 Improvements in medicine are another factor in the rise in life expectancy and improvements in the quality of life. Medical treatment can often significantly increase life expectancy without, however, ensuring a cure. Chronic and long-term illnesses needing continuing care are also on the increase.

4.8 An important challenge is the rising incidence of dementia, with sufferers requiring time-consuming care and incurring heavy costs, as well as the depression which is often associated with dementia; these conditions pose similar challenges for carers. Special services and establishments are needed in which patients may be treated with dignity and respect. This is particularly necessary because the chances of suffering from senile dementia increase as life expectancy increases. The rising incidence of suicide among older people is also a cause for concern.

4.9 Changes in social conditions are matched by changes in the attitudes, demands and capacities of those requiring care as successive generations become dependent on care. Future approaches to care must be designed with these trends in mind.

5. Ensuring access to tailored care service

5.1 Long-term care means supporting people who are no longer able to live independently and who are therefore dependent on the help of others in their everyday lives. Their needs range from mobility assistance and social care, through assistance with shopping, cooking and other housework to assistance with washing and eating. Medical qualifications are not essential for the provision of such services. This is therefore in many Member States often left to relatives, usually spouses or children, who continue to provide the bulk of long-term care services.

5.2 For the reasons outlined above family members cannot in future he expected to be available for the provision of care to the same extent as in the past. A rising number of frail older people will therefore be dependent on professional carers, who must undergo training that leads to a qualification, providing their services in older person's own home or in specialised institutions.

5.3 Long-term care can be provided in various ways. Apart from family care, professional care can be provided at home, at day centres, through neighbourhood schemes, in special care institutions or in hospitals. Persons in need of care normally require several forms of medical and non-medical care, which necessitates effective cooperation between families, professional carers and medical staff. Coordination of these services is important (interface management, case management).

5.4 A ‘one size fits all’ strategy does not make sense in the provision of long-term care. The different needs of older recipients of care require a broad range of services. This makes it particularly important to make use of experience from other countries of the nature, organisation and effect of services.

5.5 Ideally the individual ought to have freedom of choice in terms of the form of the care provided and the choice of the provider. This requires not only a wide range of available services but also the creation of appropriate conditions for competition between a number of private, not-for-profit and public providers and the promotion of competition between these organisations with a view to a steady improvement in supply. This competition needs to take place within a framework of defined quality standards, which must be appropriately monitored, in order to ensure that it is not at the expense of care recipients and, as a social service of general interest, it need to be placed under the responsibility of the legislator, who will decide on the tasks to be undertaken and the objective to be achieved, and who will evaluate the results.

5.6 The different social protection mechanisms existing in individual countries affect the way in which care is provided. If, for example, more funding is provided for care institutions than for care in the home, more people will tend to live in institutions of this kind.

5.7 There are good arguments for giving preference to home care. Many people want to continue living at home, even if they are old and ill. Home care services, using family carers, are less expensive than care in specialised institutions. This must not, however, lead to a situation where family members — particularly women — are put under pressure to bear this burden alone.

5.8 The aim should be to find the best form of care for each individual situation — taking account of the interests of all concerned. In some cases, however, there is no alternative to moving the older person to a care home.

6. Financing care systems

6.1 Methods of financing care systems vary considerably between Member States and sometimes within Member States too. The reasons for this are that long-term care is often split between different public-sector bodies and budgets, that it is often provided at local level and that there are different systems of social insurance, taxation and private insurance.

6.2 Because of their dependence on national and regional conditions and policy strategies, financing systems for long-term care will continue to differ for the foreseeable future. Because these systems are being held up to public scrutiny in many countries, the exchange of experience on the organisation and operation of individual financing instruments (such as insurance systems and tax incentives) and service provision systems (e.g. personal care budgets, financial and material contributions) is both useful and important.

6.3 The key question with regard to the long-term financing of care is: how can rising costs in this area be contained? Possible measures and strategies are listed below: — maintenance and strengthening of family care, in particular through incentive mechanisms and respite services (e.g. short-term care, holiday care, day-care facilities); — ongoing development and improvement of the supply of care services, e.g. with regard to choice, cost, quality and efficiency; — establishment of competitive structures (where possible and appropriate), in order to encourage cost-awareness and development by means of competition; — a comprehensive preventive strategy., This should range from preventive health measures and the prevention of accidents (e.g. falls in the home) via private financial provision to the development of new social networks in old age which can provide support services, and boosting older people's ability to cope with everyday problems (e.g. ability to run the household); — increased involvement of volunteers in care services (e.g. neighbourhood schemes, visiting and mobility services, assistance with care, hospice care), including cross-generational discussions with schoolchildren and young people; — the increased use of technical aids in care work and the use of information and communication technologies (e.g. smart housing, distance monitoring and older people learning to communicate via IT tools).

7. Quality of long-term care

7.1 People in need of help also have a right to service quality. To this end the European Union has set the objective of ensuring access to high-quality and sustainable care (9).

7.2 According to the reports drawn up by individual Member States, there are at present major differences in the quality standards used in the care sector, in terms of their legal force and also to the extent that standards may be applied either nationally or regionally. The responses from most countries indicate that there were too few standards and inadequate regulations.

7.3 As is the case in relation to financing, national and regional arrangements will continue to apply in this area too. In this area in particular, EU-wide exchange could provide individual Member States with valuable ideas and benchmarks for national and regional arrangements. The EESC therefore proposes that, in the framework of a joint EU-wide project, quality criteria be drawn up for long-term care, which could assist individual states as a guideline for drawing up their own standards and which take account of the increasing mobility of care workers and those in need of care.

8. The long-term care labour market

8.1 The health care and long-term care sector accounts for a significant proportion of total employment in the European Union (9.7 % of total employment in the EU in 2001), and between 1997 and 2002 the sector created 1.7 million new jobs in the EU 15. There is a significant European labour market in the care sector, part of it legal, but with some areas falling within the informal sector.

8.2 The care sector offers opportunities to groups which often experience difficulties finding employment (e.g. people rejoining the labour market, immigrants). The EESC suggests that this fact be reflected in the programmes of the national employment agencies as well as in the European employment programs (retraining, skills acquisition).

8.3 Personal services in the private household are a growth market. In a society based on the division of labour they in many cases offer the opportunity for the exercise of freedom of choice when selecting an area of employment and for some people when seeking to combine career and family. Household employment is a form of work which tends to fall outside the traditional employer/employee relationship. Black economy work needs to be eliminated and suitable conditions established for legal employment relationships.

8.4 The EESC recommends that use be made of the European Social Fund to finance training programmes, partly so as to raise the quality standards of jobs in the health care and long-term care sectors in the long-term, to prevent workers from leaving the employment market prematurely and to improve the quality, flexibility and thus the efficiency of the supply chain. Volunteers should also be involved in these training programmes.

8.5 The rapid, non-bureaucratic reciprocal recognition of relevant qualifications, which would be beneficial to the European labour market, should be an objective.

8.6 Personal care, whether medical or non-medical, is a physically and mentally demanding form of work, and it is therefore important that care workers have sufficient support and rest, to ensure not only that care is of high quality but also that care workers continue working in the sector. Overwork is a significant danger in this area. Care work is demanding and requires optimum working conditions, fair pay and social recognition.

8.7 In the overwhelming majority of cases care work is performed by women and it must therefore be included in EU measures in favour of women and gender mainstreaming.

9. Reconciling care, family and career

9.1 In its opinion entitled The family and demographic change (10) the EESC looked in detail at demographic change in the European Union and its impact on families. Demographic trends mean that in future more people will have to look after elderly relatives while also working. The development of care services should therefore also be seen as a way of lightening the burden on family carers and possibly making it easier to reconcile career and care obligations.

9.2 The social partners could promote an exchange on measures for the relief of family carers which have proved their practical worth (11).

10. Hospice work and dying with dignity

10.1 The natural end of life should not be excluded from the debate on the ageing society. In accordance with the UN principles for older people, everybody should have the right to die in the most dignified circumstances possible, which should also be in keeping with the individual's system of cultural values.

10.2 The EESC discussed this subject in its opinion entitled Hospice work — an example of voluntary activities in Europe (12). Attention is drawn to the proposals made in that connection (13).

11. Care and abuse

11.1 In its recent opinion on Elder abuse (14) the EESC looked at the problem of abuse in connection with care in the home and in specialised institutions and put forward various suggestions, to which attention is drawn here.

12. Exchange of experience through open coordination, research projects and additional activities

12.1 In view of the fact that a Community policy on long-term care is not legally possible, the EESC stresses that the open method of coordination is an extremely important way of supporting the objectives of modernisation and development of high-quality, sustainable and universally available long-term care.

12.2 In an earlier opinion (15) the EESC suggested which subjects should be the focus of analysis and exchange of experience.

12.3 In its opinion entitled Research needs in the area of demographic change — quality of life of elderly persons and technological requirements (16) the EESC identified significant research needs in the areas of prevention and treatment, qualifications in the care professions, availability of care services, and technical solutions and support for family members. The research issues addressed in the opinion are just as relevant today, as is the call set out in the opinion for the development of pan-European coordinated definitions for the care sector.

12.4 In addition, workshops, conferences and the like need to be organised to support the European exchange of experience in the development of action strategies.

12.5 Cooperation with international organisations like the OECD and the WHO should also be encouraged.

13. European law

13.1 Although long-term care does not fall directly under the remit of European law, it is significantly influenced by it via other areas of the law. While the consequences of the Directive on services in the internal market, especially for social services of general interest, are unclear, the Court of Justice nevertheless interprets the freedom to provide services strictly (17). Service providers and their employees and people receiving long-term care may find themselves in situations of legal uncertainty although the need for this type of care will increase throughout the EU. There will be considerable disparities in supply and cost between Member States, which, at least in border areas, may well result in a rise in the already-established phenomenon of medical tourism and poses major problems for the local authorities concerned. The impact on long-term care should therefore be considered when these areas of the law are being developed.

13.2 The care sector is particularly subject to the conflicting demands of competition and guaranteed availability. It should therefore be given appropriate consideration in any discussion of cross-border services, labour law and services of general interest.

Brussels, 13 March 2008. The President of the European Economic and Social Committee Dimitris DIMITRIADIS

(1) See also the Joint Report by the Commission and the Council on Supporting national strategies for the future of health care and care for the elderly, CS 7166/03, March 2003.

(2) See EESC opinion of 13.12.2007 on the Communication from the Commission to the European Parliament, the Council, the European Economic and Social Committee and the Committee of the Regions on Promoting solidarity between the generations, rapporteur: Mr Jahier (CESE 1711/2007 — SOC/277).

(3) See the EESC opinion of 14.2.2008 on Services of general interest (rapporteur: Mr Hencks) (TEN/289).

(4) On the promotion of volunteering, see the EESC opinion of 13.12.2006 entitled Voluntary activity: its role in European society and its impact, rapporteur: Ms Koller, OJ C 325, 30.12.2006.

(5) e.g. Council of the European Union, Joint Report on Social Protection and Social Inclusion 2007, Conference on The Cross-Atlantic Exchange to Advance Long-Term Care, Brussels, 2006, Conference on Long-term Care for Older Persons, 2005, inter alia.

(6) See also Communication from The Commission to the Council, the European Parliament, the European Economic and Social Committee and the Committee of the Regions — Modernising social protection for the development of high-quality, accessible and sustainable health care and long-term care: support for the national strategies using the open method of coordination, 20.4.2004, COM(2004) 304 final, and the EESC opinion on the subject of 28.10.2004, rapporteur Mr Braghin (OJ C 120, 20.5.2005).

(7) Commission Communication — Green Paper — Confronting demographic change: a new solidarity between the generations16.3.2005, COM(2005) 94 final.

(8) See EESC opinion of 14.3.2007 on The family and demographic change, rapporteur: Mr Buffetaut (OJ C 161, 13.7.2007).

(9) See Programme of Community Action in the Field of Health 2008-2013.

(10) See the EESC exploratory opinion on The family and demographic change of 14.3.2007, rapporteur Mr Buffetaut (OJ C 161, 13.7.2007).

(11) See the EESC exploratory opinion on The role of the social partners in reconciling working, family and private life of 11.7.2007, rapporteur Mr Clever (OJ C 256, 27.10.2007).

(12) See EESC own-initiative opinion on Hospice work — an example of voluntary activities in Europe of 20.3.2002, rapporteur: Ms Eulenburg (OJ C 125, 27.5.2002).

(13) See the Communication from the Commission to the Council and the European Parliament — Europe's response to world ageing — Promoting economic and social progress in an ageing world — A contribution of the European Commission to the 2nd World Assembly on Ageing of 18.3.2002, COM(2002) 143 final.

(14) See EESC exploratory opinion on Elder abuse of 24.10.2007, rapporteur: Ms Heinisch (SOC/279 — CESE 1465/2007).

(15) See footnote 3.

(16) See EESC own-initiative opinion entitled Towards the seventh Framework Programme for Research: Research needs in the area of demographic change — quality of life of elderly persons and technological requirements of 15.9.2004, rapporteur: Ms Heinisch (OJ C 74, 23.3.2005).

(17) Judgment of the ECJ C-341/05 of 18.12.2007 (Laval un Partneri Ltd v. Svenska Byggnadsarbetareförbundet et alii).