EUROPEAN COMMISSION Brussels, 7.9.2022 COM(2022) 441 final 2022/0264(NLE) Proposal for a COUNCIL RECOMMENDATION on access to affordable high-quality long-term care {SWD(2022) 441 final}



EXPLANATORY MEMORANDUM 1. CONTEXT OF THE PROPOSAL • Reasons for and objectives of the proposal The value of long-term care Long-term care has an important social and economic role. It contributes to ensuring life in dignity and well-being of those in need of care, and to protecting their fundamental rights. It also reduces inequalities, thereby improving social fairness and intergenerational solidarity. Investing in long-term care has economic returns: it creates jobs and unlocks labour resources for other sectors by alleviating the family care burden. A strong long-term care sector can help foster gender equality, as care responsibilities keep millions of women out of the labour market and/or in part-time work with a negative impact on overall labour supply and, thus, potential growth. Care responsibilities may also have a negative impact on women’s pay and old-age pensions, meaning many older women are less able to afford the care they need. The lack of adequate formal long-term care means that the care burden sometimes falls on family members, which can negatively affect their health and well-being. Long-term care needs Population ageing will increase the demand for long-term care which is already high. The number of all people across the Union potentially in need of long-term care 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%. The pool of informal carers is diminishing, as women who have traditionally carried out most of the informal care burden are increasingly employed more and retiring later. At the same time, demographic ageing also implies that the EU’s working-age population is projected to continue to decrease. Along with an increased labour demand across different economic sectors, this risks further reducing the supply of formal carers due to them moving to more attractive sectors. Long-term care challenges Long-term care systems differ in terms of their design and maturity across the Union but they face common challenges. Those challenges are related to affordability, availability, accessibility and quality, all in the context of labour shortages, pressures on public funding, and complex governance. The structural weaknesses of long-term care systems have been put into the spotlight by the COVID-19 pandemic. It highlighted the need to strengthen the resilience of care systems to external shocks and the pressing need for structural reforms and investments in long-term care. Affordability challenge Financial reasons and the lack of adequate social protection represent significant barriers to accessing long-term care. The risk that arises from having long-term care needs is generally less covered by existing social protection systems than other common risks (e.g. old-age income and healthcare) and social protection arrangements vary across the Union. In some countries, public support is available only to a small proportion of people with long-term care needs. When available, social protection is often inadequate. Even after receiving support, on average, nearly half of older people with long-term care needs are estimated to be below the poverty threshold after meeting the out-of-pocket costs of home care. Availability and accessibility challenge Access to and the variety of long-term care options are insufficient, raising equity concerns. The traditional choice of care options has been between informal care (usually provided by family members or friends, mainly women) and residential facilities (usually for severe long-term care needs or the poorest). Other options, which are more person-centred, such as home care and community-based care, have started to expand, though not evenly, across the Union. There are geographical and socio-economic barriers to access, which remains especially difficult in rural and depopulating areas. Older people with lower levels of income are more likely to need long-term care than those with higher incomes. Furthermore, persons with disabilities, who represent a large proportion of those in need of long-term care, are also confronted with accessibility challenges. Quality challenge Long-term care quality standards and their assurance mechanisms are often weak. Many Member States traditionally have a robust set of regulations and standards applicable to residential care. By contrast, such standards are often less well developed for home and community-based care. Even when in place, quality standards are often limited to basic nutrition and hygiene requirements. They do not consider the well-being and quality of life of people receiving care. Furthermore, compliance by all long-term care providers, both public and private, is uneven and many Member States lack appropriate quality assurance mechanisms. Workforce challenge Workforce shortages and non-standard forms of employment are widespread in long-term care. Most Member States report or expect significant numbers of unfilled vacancies, especially for skilled care personnel, such as nurses. Unfilled job positions are particularly high in the sub-sector of services for older people. Attracting and retaining care workers is difficult due to often poor working conditions and low wages, which could be alleviated through social dialogue. However, social dialogue plays a mixed role in long-term care. Only in few Member States are almost all long-term care workers covered by collective agreements. In other Member States, social dialogue is almost absent from the long-term care sector. Another challenge is addressing the specific situation of live-in carers, who are usually mobile or migrant workers, being particularly vulnerable, especially if engaged in undeclared work. Such workers may earn extremely low wages and their working-time arrangements, including adequate rest periods and other working conditions, may be blurry and even not compliant with labour law. Furthermore, the care sector is one of the most gender-segregated sectors. Women make up 90% of the care workforce and gender stereotypes related to care provision are pervasive. Informal care represents most care provision, but comes with its own costs. Around 52 million Europeans, that is to say 14.4% of the population aged 18 to 74, provide informal long-term care to family members or friends on a weekly basis, accounting for close to 80% of people providing long-term care at EU level. However, caring can be difficult, especially for older carers, affecting their own health and well-being. Informal care also comes with (hidden) costs to the economy and the individual. Informal carers (who are usually women) are more likely to take career breaks, opt for part-time work or withdraw from the labour market, which adds to gender gaps, and labour and skills shortages. Funding challenge

Public expenditure on long-term care is expected to further increase significantly, requiring sustainable financing. It is projected to increase from 1.7% of GDP in 2019 to 2.5% of GDP in 2050, with marked variations across Member States. This projected increase, furthermore, may be largely underestimated. It does not take into account that the current substantial contribution of informal carers, estimated currently at 2.4% of the Union’s GDP), is unlikely to remain at the same level in future, due to changing family structures and rising female employment. Fiscal sustainability can be improved by ensuring cost-effectiveness of long-term care, for example, through a coherent and integrated governance framework, support for independent living and better targeting of long-term care to personal needs to make sure, for example, that people with low care needs are not being cared for in more expensive settings for severe needs. Furthermore, more ambitious actions on health promotion and disease prevention are needed to ensure that people remain in good mental and physical health, that a strong workforce is ensured and that health care systems remain sustainable and resilient. Governance challenge In many Member States, long-term care provision is often fragmented, being organised in a complex system of services across healthcare and social care and other types of support, and subject to a national, regional or local distribution of responsibilities. This contributes to differences in the availability and quality of long-term care services and reduces cost-effectiveness. Indicators for monitoring long-term care vary and administrative data tends to be fragmented at national level and is often not available or comparable at the Union level. This hampers efficiency and limits also the possibility for effective monitoring and mutual learning. Long-term care involves a variety of players, including those 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 organisations, long-term care providers, and bodies responsible for promoting social inclusion and integration and protection of fundamental rights, including national equality bodies. Sound policy governance is needed to ensure that all the available resources are well targeted, including by collecting evidence, conducting a mapping of available infrastructure and services, individual needs assessment and gap analysis, while taking into account territorial inequalities and demographic challenges. Objectives of the proposal The European Pillar of Social Rights Action Plan announced an initiative in 2022 on long-term care. In the 2021 State of the Union speech , the President of the European Commission, Ursula von der Leyen, announced a new European Care Strategy to support men and women in finding the best care and the best life balance for them. The present proposal for a Council recommendation aims to support Member States in their efforts to improve access to affordable high-quality long-term care. It will provide guidelines on the direction of reforms to address the shared challenges of affordability, availability, quality, and the care workforce, and on sound policy governance in long-term care. That will further structure Union cooperation on long-term care, while striving for upward convergence. • Consistency with existing policy provisions in the policy area The proposal supports the implementation of the European Pillar of Social Rights , which states, 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. It also contributes to the implementation of Principle 9 on work-life balance for people with care responsibilities and Principle 17 on the rights of persons with disabilities. This proposal is a key action under the Commission Communication European care strategy. It contributes to the lifelong approach to care promoted therein and focuses on social protection for long-term care and the enabling conditions for its effective provision Policy developments and challenges in long-term care are monitored through the European Semester. In past years, several Member States received country-specific recommendations on various aspects of long-term care, including access, quality, affordability, increasing women’s participation in the labour market, and sustainability. The Employment Guidelines call for adequate and inclusive social protection systems. They also state that timely and equal access to affordable long-term care and healthcare services, including prevention and healthcare promotion, is particularly relevant, in light of the COVID-19 crisis and in a context of ageing societies. The 2022 Joint Employment Report highlights the importance of long-term care services to increase the labour market participation of women. It also underscores the fact that population ageing is expected to lead to a great increase in the demand for long-term care. The Report calls on Member States to increase the provision of quality, affordable and sustainable long-term care services. The proposal is consistent with and builds upon existing social protection policies. In particular, in the context of the Social Open Method of Coordination, Member States have agreed common objectives related to long-term care, as follows: ·to guarantee access for all to adequate health and long-term care and ensure that the need for care does not lead to poverty and financial dependency, address inequities in access to care and in health outcomes; ·to promote quality in health and long-term care and adapt care to the changing needs and preferences of society and individuals, notably by establishing quality standards reflecting best international practice and by strengthening the responsibility of health professionals and of patients and care recipients; ·to ensure that adequate and high-quality health and long-term care remains affordable and sustainable, by promoting healthy and active lifestyles, good human resources for the care sector and a rational use of resources, notably through appropriate incentives for users and providers, good governance, and coordination between care systems and institutions. The proposed Council recommendation on long-term care addresses key challenges identified in the 2021 Report on long-term care , prepared jointly by the European Commission and the Social Protection Committee. It will therefore deepen the ongoing EU-level cooperation on social protection and, more specifically, on long-term care, by establishing a shared understanding on the direction of the reforms. While there are no previous EU legislative initiatives specifically focusing on long-term care, some are of relevance to long-term care and thus complement the proposal. The Work-Life Balance Directive introduces the possibility for the employed to use a carers’ leave and promotes flexible forms of employment, which are of relevance to informal carers of working age. The current proposal refers in the recitals to the Directive as being relevant EU law. The Commission proposal to revise Regulation (EC) No 883/2004 of the European Parliament and of the Council aims to bring legal clarity and transparency regarding access to long-term care benefits when residing in another Member State. The proposal for a Council recommendation on long-term care does not as such address the free movement of people in need of long-term care or the transferability of long-term care benefits. Rather, it focuses on the coverage of long-term care by national social protection in general and on the key enabling conditions for its effective functioning, i.e. the existence of appropriate and high-quality, long-term care services and carers. This proposal is consistent with and without prejudice to Union law on working conditions as far as it applies to long-term care workers. The European accessibility act aims to improve the functioning of the single market for accessible products and services. It covers products and services that have been identified as being most important for persons with disabilities while being most likely to have diverging accessibility requirements across EU countries. Furthermore, the Web Accessibility Directive already requires websites and mobile applications of public sector bodies, including information, online contact and applications forms, to be accessible to users, in particular persons with disabilities. This proposal calls on Member States to ensure that long-term care information, services and facilities are accessible to persons with disabilities. • Consistency with other Union policies The proposal follows up the debate launched under the Green Paper on Ageing . This highlighted the need for an integrated approach to long-term care that is accessible, affordable and of high quality, that is centred around the care recipient’s needs, and that aims at supporting every individual’s independence as long as possible. Respondents considered focusing on increasing the provision of home- and community-based care as key to enable ‘ageing-in-place’. Such person-centred care services were said to be best created through co-development with all stakeholders. In addition, new technologies and digital solutions were said to improve care delivery, in particular in rural and remote areas.

3. RESULTS OF EX POST EVALUATIONS, STAKEHOLDER CONSULTATIONS AND IMPACT ASSESSMENTS • Ex post evaluations/fitness checks of existing legislation Not applicable. • Stakeholder consultations The call for evidence on the European care strategy was published on the Have your say web page and was open for public feedback from 1 to 29 March 2022. The Commission received 123 contributions, most from NGOs (64). The most recurrent topics raised during the consultations were access to and availability of care services, social protection and affordability of care services, quality of care services, care workers and informal carers, socio-economic and territorial inequalities, gender dimension, active and healthy ageing and prevention policies, financing of care services, governance/coordination aspects, potential of digitalisation and innovation for the care sector, and the COVID-19 pandemic and its impact. The targeted consultations included exploratory debates with the high-level group on gender mainstreaming (28 January 2022) and with Member State representatives in both the Social Protection Committee (17 March 2022) and the Employment Committee (1 April 2022). There was also a strategic dialogue with civil society organisations (11 March 2022), a joint hearing of the Committees of the European Parliament on Employment and Social Affairs and Women’s Rights and Gender Equality (24 March 2022) and a dedicated hearing with social partners at Union level (7 April 2022). The role of robust social protection and its impact on access to and affordability of high-quality long-term care services was highlighted by many respondents, including Member States, social partners and civil society. The importance of person-centred approaches and the need for greater integration between care and healthcare services was highlighted, especially by civil society organisations. Appropriate public funding and investment in care services, including by using all available Union instruments, were deemed crucial to that end. The need to use the Recovery and Resilience Facility for care was echoed by social partners. Improvement of working conditions in the long-term care sector was a key topic in all consultation events and written contributions. MEPs highlighted underfunding and understaffing in the care sector and its high potential for job creation and innovation. They called for addressing the low unionisation in the sector and highlighted the role of education and training in ensuring qualified workers and professionalisation. Social partners also mentioned the role of social dialogue and the importance of sufficient staffing levels to ensure quality and person-centred delivery. Social partners stressed that migrant workers, domestic workers and people in personal household services should benefit from the same social and labour rights as workers in the mainstream care sector. Member States are aware of worker shortages and some are developing strategies to attract more workers, including men, to the care sector. Several civil society organisations called for a definition of the legal status for informal carers. Regarding implementation, civil society organisations supported monitoring based on indicators and targets, and called for national action plans for implementation to be developed by Member States. Social partners considered it important to monitor progress in addressing challenges in the long-term care sector by building on European Semester framework arrangements. In the Social Protection Committee (SPC) and Employment Committee (EMCO), Member States also stressed the need to improve the evidence base and supported a continued exchange of good practices. Some Member States shared concerns regarding potentially increased administrative burden and highlighted the importance of consistency and synergies with related policy initiatives at EU and international level. During the exploratory debates with these two committees, several Member States pointed out that the initiative should be developed in full respect of national responsibilities and the principles of subsidiarity and proportionality, also taking into account the different national circumstances and set-up of care systems. The Commission received contributions or held exchanges of views with the European Economic and Social Committee (EESC) and the Committee of the Regions (CoR): ·The EESC is concerned about the precarious situation of live-in carers, who are often migrant or mobile women, and has made recommendations to improve it, including via regularisation of their situation and supporting their professionalisation. The EESC welcomes the Commission's initiative to establish a new European care strategy and calls for its swift implementation. It urges the European Commission and Member States to develop, in the short term, principles relating to care for older people within the European Pillar of Social Rights Action Plan. ·In July 2021, the CoR adopted an opinion on the Future plan for care workers and care services – local and regional opportunities in the context of a European challenge. The opinion calls on the Commission to publish a European quality framework for long-term care and for an efficient system of comprehensive data collection and analysis. The European Parliament called on the Commission to present a plan to ensure the mental health, dignity and well-being of people, including older people, and underlined the key role of adequately funded social protection schemes in making care affordable and truly accessible. It also called on Member States to ensure equal access to health and care services and on the Commission to put forward a ‘care deal for Europe’. In its most recent own initiative report ‘Towards a Common European action on care’, it called for the Commission to present an ambitious, robust and future-proof European care strategy that builds on everyone’s right to affordable, accessible and high-quality care and the individual rights and needs of both care recipients and carers, and that encompasses the entire life course, targeting and responding to the needs of people at critical periods throughout their lifetime, laying the ground for continuity of care services throughout the lifespan and fostering solidarity between generations. The Council invited Member States and the Commission to improve the availability of high-quality long-term care and the sustainability and adequacy of social protection systems, to use digitalisation to make health, social and long-term care services easily accessible and user-friendly, and to develop services that provide person-centred and integrated care, including for persons with disabilities. • Collection and use of expertise The proposal is underpinned by a Commission staff working document and is based on the most recent relevant studies and reports, including: · 2021 Long-term care report , jointly prepared by the Social Protection Committee and the European Commission (DG EMPL); ·Estimating the Effects of Social Protection for Long-Term Care in Old Age in Europe, Organisation for Economic Cooperation and Development (OECD) (forthcoming); · Challenges in long-term care in Europe , European Social Policy Network (2018); · Mapping long-term care quality practices in the EU , European Social Policy Network (2020);

· Study on exploring the incidence and costs of informal long-term care in the European Union , Ecorys (2021); · Study on the long-term care supply and market in EU Member States , KPMG (2021); · COVID-19 and older people: Impact on their lives, support and care , Eurofound (2021); · Who Cares? Attracting and Retaining Care Workers , OECD (2020); · Long-term care workforce: employment and working conditions , Eurofound (2021); · The 2021 Ageing Report: Economic and Budgetary Projections for the EU Member States (2019-2070), European Commission (DG ECFIN), Economic Policy Committee (Ageing Working Group). • Impact assessment The proposed instrument offers guidance to Member States on how to improve access to affordable, high-quality, long-term care, allowing Member States the flexibility to design and implement measures according to their national practices. Consequently, no impact assessment is needed. Furthermore, the impact of this recommendation will depend not only on how Member States implement the measures, but also on country-specific circumstances, such as the macroeconomic situation, the design of social protection systems and social services, and the structure and functioning of the labour market. Those circumstances make it difficult to disentangle the specific impact of the proposal from other factors. The proposal is accompanied by a staff working document, which takes stock of the long-term care challenges and explores possible avenues for action. • Regulatory fitness and simplification Not applicable. • Fundamental rights This recommendation respects the fundamental rights and observes the principles recognised by the Charter of Fundamental Rights of the European Union . In particular, this recommendation respects the principle of non-discrimination (Article 21 of the Charter) and contributes to safeguard the rights of the child (Article 24 of the Charter), the rights of the elderly to lead a life of dignity and independence and to participate in social and cultural life (Article 25 of the Charter), the right of persons with disabilities to benefit from measures designed to ensure their independence, social and occupational integration and participation in the life of the community (Article 26 of the Charter), the right of a family to enjoy legal, economic and social protection (Article 33 of the Charter), and the entitlement to social security benefits and social services providing protection in cases such as maternity, illness, industrial accidents, dependency or old age, and in the case of loss of employment, in accordance with the rules laid down by Union law and national laws and practices (Article 34 of the Charter). 4. BUDGETARY IMPLICATIONS This proposal has no financial implications for the Union budget. 5. OTHER ELEMENTS • Implementation plans and monitoring, evaluation and reporting arrangements It is proposed that the Commission monitors the implementation of this recommendation in the context of the European Semester and with the Social Protection Committee and the Employment Committee. Monitoring should be based on national action plans to be submitted to the Commission by Member States within 1 year of the recommendation’s adoption and subsequent progress reports. The proposal recommends that Member States nominate a national long-term care coordinator, equipped with adequate resources and mandate, who will effectively coordinate and monitor the implementation of this recommendation and act as a contact at Union level. The Commission will work jointly with the long-term care coordinators, the Social Protection Committee and the Employment Committee, as well as all other relevant stakeholders, to facilitate mutual learning, share experiences, and follow up on Member State actions taken to implement this recommendation. It is proposed that the Commission takes stock of progress regularly with the Social Protection Committee and, where relevant, the Employment Committee, regarding the implementation of this recommendation based on national action plans and progress reports from Member States. The Commission will also engage with the Social Protection Committee to further develop the framework of indicators for long-term care to help monitor the recommendation’s implementation, and prepare joint reports to analyse common long-term care challenges. Finally, after an initial period of its implementation, the Commission will take stock of progress made and report to the Council within 5 years after the adoption.

• Explanatory documents (for directives) Not applicable. • Detailed explanation of the specific provisions of the proposal Paragraphs 1-2 define the objective of the recommendation and its personal scope (all people in need of long-term care and their carers) and material scope (all types of long-term care settings). Paragraph 3 contains definitions that are applied for the purpose of the recommendation, building whenever available on definitions agreed in the context of the Social Protection Committee. Paragraph 4 recommends that Member States improve the adequacy of their social protection for long-term care, so that long-term care is timely, comprehensive, and affordable to those who need it. Paragraph 5 recommends that Member States increase the offer of long-term care services, while making sure that there is a balanced mix of services in all care settings, including by developing and/or improving home care and community-based care, closing territorial gaps, rolling out accessible innovative technology and digital solutions and ensuring accessibility for persons with disabilities. Paragraph 6 recommends that Member States ensure that high-quality criteria and standards are established and strictly applied in all long-term care settings, tailored to their characteristics, by all long-term care providers irrespective of their legal status. To this effect, Member States are invited to establish a quality framework for long-term care guided by the quality principles set out in the annex to the recommendation and includes an appropriate quality assurance mecanism. Paragraphs 7-8 recommend that Member States address skills needs and worker shortages and ensure fair working conditions. Paragraph 9 recommends that Member States support informal carers, including by training, counselling, psychological support, respite care and financial support. Paragraph 10 recommends that Member States ensure sound policy governance in long-term care by designating a national long-term care coordinator, involving all relevant stakeholders, increasing consistency with other policy areas, developing its forecasting of long-term care needs, improving contingency planning (e.g. for dealing with pandemics or other external shocks) and data collection, raising awareness, and mobilising available funding, including EU funds, for long-term care reforms. Paragraph 11 recommmends that Member States prepare and submit to the Commission a national action plan presenting measures to implement this Recommendation, taking into account national, regional and local circumstances and, subsequently, regular progress reports. Paragraph 12 sets out how the Commission intends to support the implementation of this recommendation, including by mobilising EU funding, monitoring progress in the context of the European Semester and with the Social Protection Committee and the Employment Committee, establishing a framework of indicators for monitoring, facilitating mutual exchanges, and reporting to the Council on progress within 5 years of the adoption. 2022/0264 (NLE) Proposal for a COUNCIL RECOMMENDATION on access to affordable high-quality long-term care THE COUNCIL OF THE EUROPEAN UNION, Having regard to the Treaty on the Functioning of the European Union, and in particular Article 292 in conjunction with Article 153(1), point (k) thereof, Having regard to the proposal from the European Commission,

Whereas: (1)Accessible, affordable and high-quality long-term care allows people in need of care to maintain autonomy for as long as possible and live in dignity. It helps to protect human rights, promote social progress and solidarity between generations, combat social exclusion and discrimination and can contribute to the creation of jobs. (2)In November 2017, the European Parliament, the Council and the Commission proclaimed the European Pillar of Social Rights, setting out 20 principles to support well‐functioning and fair labour markets and welfare systems. Principle 18 on long-term care states that everyone has the right to affordable long-term care services of good quality, in particular home care and community-based services. Principle 9 promotes the right to work-life balance for people with care responsibilities. Principle 17 recognises the right of people with disabilities to inclusion, in particular to services that enable them to participate in the labour market and in society. (3)Long-term care services organised by public authorities, at national, regional or local levels, are primarily considered as social services of general interest as they have a clear social function. They facilitate social inclusion and safeguard fundamental rights of older people, complement and support the role of families in caring for the oldest members of society, and provide, among others, assistance for people in permanent or temporary need for care (4)Most carers and people in need of long-term care are women. Women, on average, have lower incomes, including pensions, and are potentially less able to afford care, while at the same time living longer than men and thus more in need of care. Adequate and affordable formal long-term care services together with policies to improve working conditions in the sector and reconcile paid employment and caring responsibilities could therefore be beneficial to gender equality. (5)This Recommendation promotes the application of Articles 21, 23, 24, 25, 26, 33 and 34 of the Charter of Fundamental Rights of the European Union covering non-discrimination, equality between men and women, the rights of the child, the rights of the elderly, integration of persons with disabilities, and the rights to family and professional life and social security and social assistance. (6)This Recommendation respects the United Nations Convention on the Rights of Persons with Disabilities, which recognises the equal right of all persons with disabilities to live independently in the community, with choices equal to others. (7)The European Pillar of Social Rights action plan, adopted by the Commission on 4 March 2021, announced an initiative on long-term care, to set a framework for policy reforms to guide the development of sustainable long-term care that ensures better access to quality services for those in need, and encouraged Member States to invest in the health and care workforce, improving their working conditions and access to training. (8)The 2021 Long-Term Care Report of the Social Protection Committee and the Commission highlights that the demand for high-quality long-term care is set to rise and that increasing its provision can contribute to gender equality and social fairness. The Report identifies access, affordability, and quality as key challenges in long-term care, an appropriate workforce as key to meeting the rising demand for high-quality services, while highlighting that informal care often comes with neglected costs. (9)Population ageing is expected to increase the demand for long-term care, as decline in functional ability and the need for long-term care are associated with older ages. The number of people aged 65 or over is projected to increase by 41% over the next 30 years, from 92.1 million in 2020 to 130.2 million in 2050, while the number of people aged 80 or over is projected to increase by 88%, from 26.6 million in 2020 to 49.9 million in 2050. (10)The COVID-19 pandemic has negatively affected long-term care systems and exacerbated many pre-existing structural weaknesses, in particular the lack of quality services and worker shortages, and highlighted the urgent need to strengthen the resilience of long-term care systems and step up efforts to improve personal autonomy and facilitate independent living. (11)There are marked variations across Member States in terms of the level of public funding for long-term care, with some countries investing less than 1% of GDP, while some others spending more than 3% of GDP. In 2019, public expenditure on long-term care amounted to 1.7% of the Union’s GDP, which is less than the estimated value of hours of long-term care provided by informal carers, estimated to be around 2.5% of EU GDP. In Member States with low public expenditure on long-term care, use of formal long-term services is more limited. The growing demand for long-term care increases the pressure on public expenditure, while also calling for improving the cost-effectiveness of long-term care provision, for example, via health promotion and preventive policies, better integration and targeting of services, collecting data and evidence, and using new and digital technologies. Policies conducive to the sustainable funding of long-term care are important for the sustainability of public finances, particularly in the context of ageing population and decreasing work force in the EU. (12)Relying heavily on informal care will not be sustainable and formal care needs and pressure on public budgets are expected to increase. (13)Social protection coverage for long-term care is limited and costs often represent a serious barrier to accessing long-term care. For many households, financial reasons are at the top for not using (more) professional home-care services. Without adequate social protection, the estimated total costs of long-term care can often exceed a person’s income. While arrangements of social protection vary across Member States, in some, public support is available only to a small proportion of people with long-term care needs. Even when available, social protection is often insufficient, as even after receiving support, on average, nearly half of older people with long-term care needs are estimated to be below the poverty threshold after meeting the out-of-pocket costs of home care. (14)Many people cannot access the long-term care they need due to an overall low offer of services and, among other reasons, to the limited range of long-term care options and territorial gaps. In many Member States, the choice of long-term care is limited. Where there is a choice, it is mainly between informal care and residential care. The supply of home and community-based long-term care is still low. In addition, territorial disparities in long-term care provision makes equal access to long-term care difficult, especially in rural and depopulating areas. The choice is even more limited for persons with disabilities due to uneven accessibility of care services. (15)In long-term care, quality depends on an effective quality assurance mechanism, which in many Member States is lacking or is under-resourced. Quality assurance is often insufficient in home and community-based care. While quality of residential care is more regulated, quality standards often focus on clinical outcomes and do not address sufficiently the quality of life of people receiving care and their ability to live independently. Even when quality standards are in place, their enforcement is not always effective, often due to inadequate administrative set-up or lack of resources. Lack of high quality standards applied strictly to both public and private care providers leads to situations of neglect and abuse of care recipients and poor working conditions for carers. (16)Long-term care has an important social value and job creation potential, but Member States struggle to attract and retain care workers due to inadequate skills, difficult working conditions and low wages. (17)The skills required in the care sector are increasingly complex. In addition to traditional skills and competences, carers often need to have technological expertise related to using new technologies, digital skills and communication skills, often in a foreign language, and skills to handle complex needs and work in multidisciplinary teams. Without appropriate education and training policies, including on-the-job, the skills requirements can act for many as a barrier to enter or progress further in the sector. (18)Long-term care workers often experience non-standard work arrangements, irregular working hours, shift work, physical or mental strains and low wages. Low coverage of long-term care workers by collective agreements and limited public expenditure in long-term care contribute to low wages in the sector. (19)Certain groups of workers, including live-in carers or domestic workers providing long-term care, face particularly difficult working conditions, including low wages, unfavourable working-time arrangements, undeclared work, and non-compliance with essential labour protection rules and irregular forms of employment. The 2011 Domestic Workers Convention (No. 189) of the International Labour Organization lays down basic rights and principles, and requires country competent authorities to take a series of measures with a view to ensure decent working conditions for domestic workers.

(20)Informal care has been essential in long-term care provision, as informal carers, mostly women, traditionally carry out the bulk of caregiving, often due to a lack of accessible and affordable formal long-term care. Providing informal care can negatively affect carers’ physical and mental health and well-being and is a significant obstacle to employment, particularly for women. That has an immediate effect on their current income, and affects their old-age income due to a reduced accrual of pension rights, which can be even more significant for carers with additional childcare responsibilities. Children and young people with a chronically ill family member tend to have more mental health problems and more adverse outcomes with long term effect on their income and inclusion in society. (21)The organisation of long-term care differs across the Union. Long-term care is organised in an often complex system of services across health and social care and sometimes other types of support, such as housing and local activities. There are also differences in terms of the roles played by the national, regional and local levels of administration. Indicators used for monitoring long-term care also vary and administrative data are often not available or comparable at Union level. (22)Long-term care stakeholders include those in need of long-term care, their family members and organisations representing them, relevant authorities at national, regional, and local level, social partners, civil society organisations, long-term care providers, and bodies responsible for promoting social inclusion and integration and protection of fundamental rights, including national equality bodies. Social economy bodies, including cooperatives, mutual benefits societies, associations and foundations, and social enterprises, are important partners for public authorities in the provision of long-term care. (23)The European Semester process, supported by the Social Scoreboard, has highlighted the challenges in long-term care, resulting in some Member States receiving country-specific recommendations in that area. The Employment Guidelines underline the importance of ensuring availability of affordable, accessible and quality long-term care. The Open Method of Coordination for Social Protection and Social Inclusion aims to promote accessible, high-quality and sustainable long-term care and supports that objective through monitoring, multilateral surveillance of reforms, thematic work, and mutual learning. The Social Protection Committee developed a European quality framework for social services, including long-term care. However, there is still no Union comprehensive framework to guide national reforms in long-term care. (24)The Union provides many funding opportunities for long-term care, targeting different investment priorities in accordance with the specific regulations of the various funding programmes, which include the European Regional Development Fund (with priority focus on non-residential family- and community-based services), the European Social Fund plus, and its Employment and Social Innovation strand, the Just Transition Fund, Horizon Europe, the Digital Europe Programme, support to design and implement reforms through the Technical Support Instrument, and the Recovery and Resilience Facility for eligible reforms and investments in the context of the recovery from the COVID-19 pandemic. (25)This Recommendation builds on Union law on working conditions regarding transparent and predictable working conditions, work-life balance, and health and safety at work, applicable and relevant to long-term care. (26)In full respect of the principles of subsidiarity and proportionality, this Recommendation is without prejudice to the powers of Member States to organise their social protection systems and does not prevent them from maintaining or establishing provisions on social protection which go beyond those recommended, HAS ADOPTED THIS RECOMMENDATION: OBJECTIVE AND SCOPE 1.This Recommendation aims to improve access to affordable, high-quality long-term care to all people who need it. 2.This Recommendation concerns all people in need of long-term care, and formal and informal carers. It applies to long-term care provided across all care settings. DEFINITIONS 3.For the purpose of this Recommendation, the following definitions apply: (a)‘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); (b)‘formal long-term care’ means long-term care provided by professional long-term care workers, which can take the form of home care, community-based or residential care; (c)‘home care’ means formal long-term care provided in the recipient’s private home, by one or more professional long-term care worker or workers; (d)‘community-based care’ means formal long-term care provided and organised at community level, for example, in the form of adult day services or respite care; (e)‘residential care’ means formal long-term care provided to people staying in a residential long-term care setting; (f)‘informal care’ means long-term care provided by someone in the social environment of the person in need of care, including a partner, child, parent or other relative, who is not hired as a long-term care professional; (g)‘independent living’ means that all people in need of long-term care can live in the community with choices equal to others, have the opportunity to choose their place of residence and where and with whom they live on an equal basis with others, and are not obliged to live in a particular living arrangement;

(h)‘domestic long-term care worker’ means any person engaged in domestic work who provides long-term care within an employment relationship; (i)‘live-in carer’ means a domestic long-term care worker who lives in the care recipient’s household and provides long-term care. ADEQUACY, AVAILABILITY AND QUALITY 4.Member States should improve the adequacy of social protection for long-term care, in particular by ensuring that long-term care is: (a)timely, allowing people in need of long-term care to receive the necessary care as soon as, and for as long as, needed; (b)comprehensive, covering all long-term care needs, arising from mental and/or physical decline in functional ability, assessed on the basis of clear and objective eligibility criteria; (c)affordable, enabling people in need of long-term care to maintain a decent standard of living and protecting them from poverty due to their long-term care needs. 5.Member States should increase the offer of long-term care services, while providing a balanced mix of long-term care options and in all care settings to cater for different long-term care needs and supporting the freedom of choice of people in need of care, including by: (a)developing and/or improving home care and community-based care; (b)closing territorial gaps in availability of and access to long-term care, in particular in rural and depopulating areas; (c)rolling-out accessible innovative technology and digital solutions in the provision of care services, including to support independent living; (d)ensuring that long-term care services and facilities are accessible to persons with specific needs and disabilities, respecting the equal right of all persons with disabilities to live independently in the community, with choices equal to others. 6.Member States should ensure that high-quality criteria and standards are established for all long-term care settings, tailored to their characteristics, and strictly applied to all long-term care providers irrespective of their legal status. To this effect, Member States should ensure a quality framework for long-term care which is guided by the quality principles set out in the Annex and includes an appropriate quality assurance mechanism, that: (a)enforces compliance with quality criteria and standards across all long-term care settings and providers in collaboration with long-term care providers and people receiving long-term care, (b)provides incentives to and enhances the capacity of long-term care providers to go beyond the minimum quality standards and to improve quality continuously, (c)secures sufficient resources for quality assurance at national, regional and local levels and encourages long-term care providers to have budgets for quality management, (d)ensures, where relevant, that requirements regarding the quality of long-term care are integrated in public procurement, (e)promotes independent living and inclusion in the community in all long-term care settings. CARERS 7.Member States should ensure fair working conditions in long-term care, in particular by:

(a)promoting national social dialogue and collective bargaining in long-term care, including supporting the development of attractive wages in the sector, while respecting the autonomy of social partners; (b)without prejudice to Union law on occupational health and safety and while ensuring its effective application, promoting the highest standards in occupational health and safety for all long-term care workers; (c)addressing the challenges of vulnerable groups of workers, such as domestic long-term care workers, live-in carers and migrant care workers, including by providing for effective regulation and professionalisation of such care work. 8.Member States, in collaboration, where relevant, with social partners, long-term care providers and other stakeholders, should address skills needs and worker shortages in long-term care, in particular by: (a)designing and improving the initial and continuous education and training to equip current and future long-term care workers with the necessary skills and competences, including digital; (b)building career pathways in the long-term care sector, including through upskilling, reskilling, skills validation, and information and guidance services; (c)establishing pathways to a regular employment status for undeclared long-term care workers; (d)exploring legal migration pathways for long-term care workers; (e)strengthening professional standards, offering attractive professional status and career prospects to long-term carers, including to those with low or no qualifications; (f)implementing measures to tackle gender stereotypes and gender segregation and to make the long-term care profession attractive to both men and women. 9.Member States should establish clear procedures to identify informal carers and support them in their caregiving activities by: (a)facilitating their cooperation with long-term care workers; (b)helping them to access the necessary training, counselling, healthcare, psychological support and respite care; (c)providing them with adequate financial support, while making sure that such support measures do not deter labour market participation. GOVERNANCE, MONITORING AND REPORTING 10.Member States should ensure sound policy governance in long-term care and ensure a coordination mechanism to design and deploy actions and investments in that area, in particular by: (a)appointing a national long-term care coordinator, supplied with adequate resources and a mandate enabling the effective coordination and monitoring of the implementation of this Recommendation at national level and acting as a contact point at Union level; (b)involving all relevant stakeholders at national, regional and local levels in the preparation, implementation, monitoring and evaluation of long-term care policies and improving the consistency of long-term care policies with other relevant policies, including healthcare, employment, education and training, broader social protection and social inclusion, gender equality, and disability rights; (c)developing a national framework for data collection and evaluation, underpinned by relevant indicators, collection of evidence, including on gaps and inequalities in long-term care provision, lessons learned and successful practices, and feedback from people receiving care and other stakeholders; (d)developing a mechanism for forecasting long-term care needs at national, regional and local levels and integrating it into the planning of long-term care provision;