EUROPEAN COMMISSION Brussels, 7.9.2022 SWD(2022) 440 final COMMISSION STAFF WORKING DOCUMENT Summary of consultation activities Accompanying the document Commission Communication on the European care strategy {COM(2022) 440 final}



Contents 1. INTRODUCTION 2. MAIN ELEMENTS OF THE STAKEHOLDERS’ CONSULTATIONS 2.1 Call for evidence on Have your Say website 2.2 Targeted consultations 2.3 Inter-institutional process 3. Challenges and opportunities for the European Care Strategy – Main findings from the consultations 3.1 On the European Care Strategy in general 3.2 Gender dimension in care 3.3 Socio-economic and territorial inequalities 3.4 Social protection and affordability of care services 3.5 Access and availability of care services 3.6 Quality of care services 3.7 Care workers 3.8 Informal carers 3.9 Potential of digitalisation and innovation for the care sector 3.10 Financing of care services 3.11 Governance and implementation

3.12 Active and healthy ageing and prevention policies 3.13 The impact of the COVID-19 pandemic Annex 1: List of stakeholders who submitted feedback on the European Care Strategythrough Responses to the Call for Evidence



1.INTRODUCTION The 2022 Commission Work Programme announced a European care strategy to address both carers and care receivers, from childcare to long-term care. The strategy sets a framework for policy reforms to guide the development of sustainable long-term care that ensures better and more affordable access to quality services for all. It also helps close the gender employment gap and contributes to gender equality, including by revising the Barcelona targets on childcare. Finally, it sets out ways to improve the working conditions in the care sector. The Strategy thus supports the implementation of several principles of the European Pillar of Social Rights. The package comprises three elements: (i) a Chapeau Communication on a European Care Strategy, (ii) a proposal for a Council Recommendation on the revision of the Barcelona targets on early childhood education and care, and (iii) a proposal for a Council Recommendation on access to affordable high-quality long-term care. The European care strategy aims to respond to calls for a strategic and comprehensive approach to care, including by the Member States, the European Parliament, the Committee of the Regions, the European Economic and Social Committee, social partners, civil society, care providers and other stakeholders. The initiative builds on the input gathered via three public consultations, notably on the European Pillar of Social Rights action plan , the Green paper on ageing , and the Gender equality strategy . As concerns the consultation on the European Pillar of Social Rights action plan, there were calls for comprehensive EU action on long-term care to address common challenges, including via minimum standards, quality guidelines, and monitoring mechanisms. The importance of enhanced mutual learning and exchanges of best practice was emphasized. Specific feedback was received inter alia on the attractiveness of the care sector, working conditions, importance of social dialogue, occupational health and safety, prevention, person-centred care, community-based care, and support for informal carers. There was furthermore a call for a Care Package including a revision of the Barcelona targets. Accessible and affordable quality long-term care and childcare services is considered crucial for closing gender gaps. Respondents to the consultation launched by the Green Paper on Ageing 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 aims at supporting individual independence as long as possible. The right to live in dignity was stressed, with NGOs in particular calling for Member States to increase levels of public spending on long-term care and expand the provision of formal long-term care services. Additional feedback was received inter alia on the importance of social protection coverage for long-term care risks, the importance of increased provision of home and community-based care to enable ‘ageing-in-place’, the need to tackle long-term care staff shortages, the role of cities and local authorities in long-term care provision, the role of technology and prevention as drivers for cost-effectiveness and the need to reconcile adequate and affordable long-term care coverage with cost-effectiveness and financial sustainability. Respondents to the public consultation on the Gender equality strategy ranked making childcare and other dependents’ care more available, accessible, affordable and of high quality and giving support to informal carers as key priorities for EU action to increase women’s participation in the labour market. Next to this, they highlighted the importance of equal sharing of caring activities between parents, as well as improving the conditions of part-time work, flexible working arrangements and family leaves to make them valid career options for both women and men. Furthermore, there was support for actions aimed at improving childcare provision targeting in particular under-served groups (e.g. indigenous, low-income, single parents, rural areas, etc.). Enhanced access of parents to affordable, accessible and quality early childhood education and care services was considered essential to encourage female labour market participation including for women with disabilities. The Staff Working Document describes the key elements of the stakeholders consultations, which complemented the above-mentioned public consultations (section 2), as well as the main findings (section 3). 2. MAIN ELEMENTS OF THE STAKEHOLDERS’ CONSULTATIONS 2.1 Call for evidence on the Have your Say website On 1 March 2022 the European Commission published a Call for Evidence on the European Care Strategy and the accompanying proposals for Council Recommendations, inviting stakeholders to provide their input. The Commission received feedback both through the dedicated website and direct submissions from stakeholders. Stakeholders and citizens could submit their feedback on the European care strategy via a dedicated web page . The Commission received 123 contributions, with 64 submissions (52%) coming from NGOs. Public authorities accounted for 8% of total submissions, business associations for 8%, EU citizens for 7% and trade unions for 5%. Further contributions came from business organisations (5%), research institutions (1%) and other (15 %). Distribution of contributions per type of stakeholder (N=123)

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. 2.2 Targeted consultations In addition to the Call for Evidence, the Commission invited stakeholders to provide input through targeted consultations which included: ·an exploratory debate with the High Level Group on Gender Mainstreaming (28 January); ·exploratory debates with the Member States’ representatives in the Social Protection Committee (17 March) and Employment Committee (1 April); ·a strategic dialogue with civil society organisations (11 March); ·a joint hearing of the Committees of the European Parliament on Employment and Social Affairs and Women’s Rights and Gender Equality (24 March); ·and a dedicated hearing with EU-level social partners (7 April). 2.3 Inter-institutional process The Commission received contributions or held exchanges of views with the European Parliament, the Council, the European Economic and Social Committee (EESC) and the Committee of the Regions (CoR). The European Parliament, in its Resolution of 17 December 2020, called on the Commission to present a plan to ensure the mental health, dignity and wellbeing of people, including the elderly, and in its Resolution of 7 July 2021, underlined the importance of fully protecting the right to care and support for older people and emphasised the key role of adequately funded social protection schemes in making care affordable and truly accessible. It called on the Member States to ensure equal access to health and care services, including at home, as well as residential or community-based long-term care and palliative care, without discrimination on any grounds, and on the Commission to put forward a ‘care deal for Europe’. During the joint hearing of the Committees of the European Parliament on Employment and Social Affairs and Women’s Rights and Gender Equality on the European care strategy of 24 March 2022 all political groups welcomed the European care strategy. Key challenges and avenues for actions included the underfunding and understaffing of the care sector, low unionisation in the sector; the need to better recognise job creation and innovation potential and improve working conditions and education and training opportunities as a way to ensuring qualified staff and professionalization. There were further calls for more public investments to expand services in order to offer a choice to those in need of care and their families, and more focus on independent living. The strong gender dimension of care policies and the burden placed in informal carers were highlighted as well as the need to have in place supporting measures and to expand formal long-term care services to establish the principle of freedom of choice. Issues such as quality of care, working conditions, including for migrant workers, the need to monitor progress as well as take into account the Member States competences in this policy area were also highlighted. In its most recent own initiative report ‘Towards a Common European action on care’, the European Parliament 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 the Member States and the Commission to improve the availability of high-quality long-term care and the sustainability and adequacy of social protection systems , use digitalisation to make health, social and long-term care services easily accessible and user friendly , and develop services that provide person-centred and integrated care, including for persons with disabilities . The EESC welcomed the Commission's initiative to establish a new European Care Strategy and called for its swift implementation. It urged the Commission and the Member States to develop in the short term the principles relating to care for older people within the framework of the European Pillar of Social Rights Action Plan. In a previous instance, EESC highlighted the precarious situation of live-in carers, who are often migrant or mobile women, and set out a number of recommendations to improve it, including via regularisation of their situation and supporting their professionalisation . Most recently, in its draft opinion Health Workforce and Care Strategy for the future of Europe SOC/720, which is scheduled for adoption in September 2022, the EESC stressed the need for a transformative approach to care, going beyond minimum standards and providing for a quality eco-system for care, which should be affordable, and available. Addressing workforce-related challenges was also identified as a key priority. The CoR adopted in July 2021 an opinion on the Future plan for care workers and care services – local and regional opportunities in the context of a European challenge , which stresses the need for a European quality framework for LTC services and for a comprehensive data collection and analysis.



3.Challenges and opportunities for the European care strategy – Main findings from the consultations

3.1 On the European care strategy in general Overall feedback indicates that, while care systems across the Union face common challenges and structural weaknesses, they have a key role in enhancing social fairness, gender inequalities and are as such a social investment. Member States are responsible for designing and delivering long-term care and there are significant differences in the way they organise and fund care systems. However, there are common challenges and structural weaknesses , which were especially highlighted by the COVID-19 pandemic. Such challenges include availability, access, affordability, quality, workforce shortages and working conditions, and insufficient support for informal carers. At the same time, investment in care is a social investment, with multiple returns for individuals, societies and economies. Strong care systems reduce inequalities, enhance social fairness and intergenerational solidarity. High quality early childhood education and care facilitates children’s personal development and social integration and later on their social and labour market outcomes, thus breaking the intergenerational cycle of poverty. Accessible, affordable and high-quality long-term care helps persons in need of care maintain autonomy and live in dignity for as long as possible, while also protecting human rights and preventing poverty and social exclusion. Adequate care systems foster gender equality, by reducing gender gaps in employment, pay and pensions. Care has a great economic potential. New opportunities arise in the silver and care economy, resulting from the growing demand for care services. In addition to contributing to gender equality, addressing care needs also leads to job creation and supports strong local communities. A right-based approach to care is often called for. Some civil society organisations (SSE, Social Platform, Eurodiaconia, ESN) call for a comprehensive European Care Guarantee that approaches care as a right which people have throughout their lives, ensuring access to quality and affordable social care for everyone whenever it is needed, and particularly for persons in vulnerable situations. Next to high quality services, a Care Guarantee would also help to enable framework conditions for social care services across Europe and equally support upward convergence amongst Member States’ care strategies (SSE). As part of the Care Guarantee, Member States could adopt care schemes allowing workers wishing to leave their job to provide informal care for relatives to receive poverty-proof wages. This would be in combination with adequate education and training opportunities for the carers (SSE). Other civil society organizations (NCPE, EWL) are calling for a Care Deal for Europe to complement the European Green Deal, since they consider caring for the planet and caring for each other as part of the same continuum. A Care Deal for Europe would include investment in care provision, work-life balance policies and the re-evaluation of the care sector, particularly with regard to training provision, working conditions and pay (NCPE). Trade unions stressed that the right to care should be universal, accessible to all no matter where they live, with some additional support to vulnerable groups, and they called for an integrated and lifelong approach to care, asking also to cover healthcare and decent incomes (EPSU, ETUC). A person-centred approach to care is strongly encouraged. Concretely, it should be based on human rights, dignity, inclusiveness, non-discrimination and solidarity. It is imperative that more efforts be directed towards fostering home and community-based care provision (Eurohealthnet, SSE, ESN, AGE). Choice is regarded as a fundamental element of the right to long-term care (AGE). Therefore, a continuum of long-term care services would enable each person to have the greatest freedom of choice, depending on his or her specific circumstances (Santa casa, HU in SPC). To have a fundamental rights-based approach with a rights of the child perspective, improving access to quality and affordable childcare is necessary (ERGO network). An inclusive and holistic approach is also deemed crucial. Strengthening the rights of people in need of care and of their caregivers to participate in decision-making both at political and individual level is conducive to this (BAGSO). Caregivers and care recipients from varied backgrounds have to be involved (ERGO), including individuals and organisations representing people from different ethnical and socio-economic backgrounds, persons living with (rare) diseases and disabilities (ERGO, ViiV, EURORDIS, Inclusion Europe). Tackling discrimination and stigma is considered necessary, for instance through tailored education programmes, since health and social workers who are well trained and appropriately skilled are champions for addressing discrimination in health and social settings (ViiV). There is also a need for a holistic approach that brings healthcare professionals and formal and informal carers into closer partnership (CCI Europe). The Care strategy should aim to increase both awareness and use of evidence-based palliative care across Europe (CCI Europe, BAGSO). A resilient ecosystem for care services is expected to contribute to quality, affordable, available, and accessible care infrastructures in all Member States (Social Platform). It has to be ensured that care is an integral part of a sustainable economic model (NCPE). The public discourse should be reoriented towards the value of care instead of focusing solely on its costs (Incare). Moreover, some respondents highlighted that people who do not have an EU nationality but live in the EU should be fully considered in the European care strategy (LaStrada et al). Synergies have to be ensured and nurtured with other Union initiatives (e.g. the EU Pillar of Social Rights action plan; the European strategy for the rights of persons with disabilities; the Gender equality strategy; the Work-life Balance Directive; the Council Recommendation on the European Child Guarantee; etc.). Unlocking the job creation potential of the care sector is of particular importance (Social Platform, Red Cross). Member of the European Parliament stressed the current underfunding and understaffing of the care sector and its high job creation and innovation potential. International organisations such as the International Labour Organisation (ILO) and the World Health Organisation (WHO) pointed to the need for transformative care policies ensuring decent work for care workers and quality care for those in receiving it, including through integrated and person-centred approaches. 3.2 Gender dimension in care Women form the majority of the workforce in all sectors related to care - health, education, and long-term care and they carry the lion share of informal care work, too (EWL, FES/FEPS, EFPIA). Care work is often undervalued and underpaid, bringing along lifelong consequences (EWL, CAI). This has an impact on women’s economic independence, access to social rights and particularly pensions, as the high gender pension gap attests (40% EU average) (EWL). Older women are also more in need of long-term care, but at the same time more exposed to poverty risks. For example, women are disproportionately impacted by Alzheimer’s disease (EFPIA). Given that the majority of informal carers are women, women are exposed to a considerable risk of economic hardship and poor health outcomes (EFPIA). Moreover, there is a need to attract a more gender-balanced workforce into the care sector (COFACE). Investments, decent wages and training are part of the solution. There are various suggestions on ways to address the above-described issues. First, it is essential to develop sustained investment in public services and social infrastructure, so that there is a lesser need for informal care provision (NWC). Second, it is crucial to gradually increase salaries in the care sector in order to reflect their high value for the society (CZ Ministry of Labour and Social Affairs). Simultaneously, efforts are needed to combat gender stereotypes in care as well as within the household and the family, so that more men can be attracted to work in the care sector (NCPE, CZ Ministry of Labour and Social Affairs). Guidance on national tax and benefits systems as well as on fiscal and pension policies for carers was called for (NCPE, LaStrada et al, EWL). Next, increased public funding should be dedicated to the training and education of informal carers and formal care workforce (FES and FEPS). There is a correlation between better funding and the availability of qualified staff (AT in SPC). Migrant carers, gender and racial stereotypes, discrimination and violence should also be addressed accordingly (LaStrada et al, EWL). Lack of care is an obstacle for women’s labour market participation and entrepreneurship. Employers’ organisations highlighted that such lack of care services does not only concern childcare (Inclusion Europe), but also afterschool care and care for sick children (BusinessEurope, SMEunited) and pointed to the need to have more ambitious childcare targets, to include another target regarding after-school services (BusinessEurope). There is a particular challenge for single parents, most of whom are women (ES in SPC). Finally, it is important also to provide incentives for businesses to put in place support measures for workers with family responsibilities (CONFINDUSTRIA). 3.3 Socio-economic and territorial inequalities Families and individuals in remote or rural areas often face more difficulties in the access to care services (Federation of Catholic Family Associations in Europe, City of Ghent). The European care strategy is expected to play a role in addressing socio-economic and territorial inequalities. It is expected to create a level-playing field to ensure a balanced provision of accessible, affordable and high-quality care services across regions and countries (CESI, REIF) for all groups of the population that are in need of care (DSV). A decisive factor is the presence in the territories of services capable of meeting the needs of resident populations and, in particular, of workers (CONFINDUSTRIA). This is also crucial for allowing women to participate in the labour market and social life (CONFINDUSTRIA). Community-based services could be helpful to achieve this, including social economy initiatives, to create local jobs and respond to community needs where they arise (ERGO). Territorial inequalities in access could be tackled through monitoring, strengthened administrative capacity and enhanced use of ICT. Digital solutions implemented in long-term care and healthcare service, as well as digital assistance systems and care applications can reduce inequalities in access to care (DSV). Additionally, it is useful to establish close and constant monitoring activities at regional level and to strengthen the administrative capacity (CONFINDUSTRIA). Investments in care should meet the regional needs (DE in SPC). Expansion of mobile home-patient care also has a positive role to play (Kinderpalliativteam). Furthermore, it is of paramount importance to make sure that people in need of care (and not only) have proper access to health services, independently of socio-economic status (Platform for better oral health in Europe, CCI Europe). There is a need for a special focus on increasing participation of vulnerable children in early childhood education and care (FYFPC). Families in vulnerable situations need to be informed and be consulted in the development of early childhood education and care services (COFACE/ FYFPC). High-income families with a highly educated mother use childcare more often than families with a lower socio-economic status (City of Ghent). There is a need to provide diversity education and awareness about Roma language, culture and history in order to increase participation of Roma children in early childhood education and care (ERGO). Moreover, there is a need for inclusive enrolment systems the participation of children from disadvantaged backgrounds to ensure a social mix (EUROCITIES). The reformed EU Roma Strategic Framework for equality, inclusion and participation for 2021-2030 promotes empowerment of Roma young people and children to overcome socio-economic gaps. In this sense, it is important to pursue efforts to reach the proposed target to cut the gap in participation in early childhood education and care by at least half. 3.4 Social protection and affordability of care services

Social protection coverage for long-term care is mixed and in general limited, while affordability of childcare continues to be a barrier to access. Loss of autonomy, its management and occupational aspects affect all ages through disability, illness or aging and are addressed through support in different care settings. This solution can be expensive and it is often not well covered by public funds being financed by insurances (AEIP). Hence, loss of autonomy is an increasingly prevalent risk considered within social protection systems (ESIP). It is highlighted that there should be a social protection approach to care (AGE), with financial barriers for persons with disabilities being tackled (Inclusion Europe). Parents and caregivers of children with cancer, in particular, should be entitled to an extraordinary leave tailored to the intense period of cancer treatments (with an employment guarantee) with early and ongoing assessment of their mental health needs (CCI Europe). Furthermore, Member States should ensure effective and free access to high quality ECEC for all children, including migrant children (LaStrada et al) as well as a universal non-discriminatory approach to child benefits, regardless of migration or residence status (NCPE). Special attention is needed for families in vulnerable situations who should be informed and consulted in the development of early childhood education and care services and extra efforts should be made to reach out and provide early childhood education and care services adapted to those families in an inclusive, accessible and non-stigmatising way (EASPD). Strengthening public provision of care is seen as key to implementing the right to care. Member States should improve affordability of care services for low-income individuals and families, including migrants (LaStrada et al). Member States should invest, including by making use of EU funds, in the provision of public services and subsidised, well-regulated private service provision (LaStrada et al). Caution should be exercised to avoid promoting the commercialisation of care (EPSU). Furthermore, the social protection systems should evolve to be fully individualised to reflect the diversity of today’s lives and to promote an equal division of paid work and care (CAI). Care-friendly and gender-responsive social protection systems are needed. This would entail promoting social protection systems based on a “universal carer model” and ensuring that social benefits recognise and compensate the cost of care and avoid reproducing gender inequalities. It also means ensuring that social protection is extended to workers in the informal economy and care credits are implemented as part of social protection systems (ILO). Civil society organisations echoed this call. It is important to introduce ‘care credits’” to the benefit of both women and men and to fairly take these credits into account in pension entitlements (LaStrada et al, NCPE, MMM). Career break entitlement (e.g. the Belgian ‘time-credit’ system) (MMM) should ensure income compensation during longer periods of leave for care duties (NCPE). Moreover, unpaid care work should be considered as essential work giving access to social rights (e.g. access to social security, education and training) (MMM). The overall goal should be building robust public social protection systems for those needing care and those working in the sector (LaStrada et al, EPSU). Incentives could be provided to companies that voluntarily provide to their workers in-company care services, supplementary healthcare, etc. (CONFINDUSTRIA). Flexible working arrangements by choice, adequate care leaves and access to quality and affordable services are needed in order to increase the participation of childcare (EASPD). A good coordination between family leaves, childcare and provision of other types of support is necessary in this regard. Financial barriers should be removed by offering places based on income-related rates to increase access to childcare (City of Ghent). Moreover, strengthening the provision of publicly funded care services is called for (NCPE). Robust social protection has a positive impact on access to and affordability of high-quality care services. Trade unions stressed that long-term care needs should be covered by social protection and all workers (including platform workers) need to contribute to social security (EPSU), while the employers cautioned that there is already a lot of investment in social protection, so a balanced approach is needed which look into possible savings and reallocation of existing social protection resources (BusinessEurope). SGI Europe called for more public investments in care services. 3.5 Access and availability of care services More availability and integration of home care and community-based care services and person-centred approaches facilitate access to care. The European care strategy is expected to ensure that all people living in the EU have access to quality care services on the basis of need, regardless of their migration, legal or residence status (La Strada et al, Red Cross). This entails early childhood education and care for children as well as long-term care for persons in need of all ages, including persons with disabilities, cancer, rare diseases, etc. (SIOP Europe, ENIL, MMM). Person-centred and user-led, care services should be flexible and inclusive in order to allow for adaptation to the individual needs and choice (VÖWG, Vienna Social Fund, ENIL). Independent living and social inclusion should be promoted (ENIL). This necessitates more availability and integration of home care and community-based care services (Eurocarers, Red Cross, European Disability Forum), allowing people in need of care to exercise their freedom of choice and stay (longer) in their own home if wished so (Caritas Europe), as well as community-based palliative care and alternatives to institutional care (VÖWG, ENIL, European Disability Forum). Care services need to be developed and expanded according to the needs of the population (Vienna Social Fund). More options over their live choices have to be provided also to informal carers (EASPD). High-quality and inclusive early childhood education and care is essential to support the inclusion of all children into society (ESIP) and therefore should be available to all families through a range of strategies, including a shared definition of high-quality early childhood education and care and targeted measures towards identifying which children are from disadvantages families (EASPD). Care services are a public good. Employers stressed that the state should have a very strong role in providing care services, while also acknowledging that privatisation of care is increasing (BusinessEurope) and trade unions pointing to risks of low quality and profit-driven approach (FERPA). Employers called for a level playing field between private and public provision, with similar standards applied across the board. They also mentioned the important role of public-private partnerships and responsibilities devolved to regional and local governments (BusinessEurope). 3.6 Quality of care services Ambitious quality standards on care are needed. The European care strategy is expected to facilitate the development and promotion of ambitious common quality standards on early childhood education and care and long-term care services, rooted in a human rights-based approach, with a strong focus on social justice, non-discrimination and equality (Social Platform, EWL, Eurocarers, EFSI, MMM). Quality standards of care services and quality control should be implemented, especially in childcare (Caritas Europe). Effectiveness, safety and people-centredness are key ingredients of quality care (Eurocarers). Improved cleaning and enhanced infection prevention and control are also integral elements of high-quality care, since they can help save lives. In early childhood education and care, staff shortages and the lack of resources for space remain big hurdles that need to be tackled to improve the quality of care services (Eurocities and the Municipality of Milan). Quality monitoring and assurance systems should be further developed. This should involve care service users, care workers and informal carers in the process (LaStrada et al, Eurocarers). Special attention should be given not only to the quality of care activities (technical quality), but also to the way the care is provided (functional quality) and the effect of the quality of care on the quality of life (EAN). A common definition on quality would also help to address discrepancies between Member States (EASPD). Regulatory arrangements such as certification could ensure that the care provided meets safety and quality criteria (MGEN). Integrated care is viewed as a tool to ensure quality and responsiveness of care to individual needs. This includes different needs of older persons, persons with disabilities, persons with mental health problems and cancer patients (Generalitat de Catalunya, TBCT). High-quality services also mean that caregivers have strong relationships with the people they support and can adapt the services to the beneficiaries’ preferences (Red Cross). Hence, mechanisms for quality assurance that are based on continuous quality improvement need to be promoted and strengthened (Red Cross). Not-for-profit provision of care should be prioritised, ensuring a focus on quality care and care work, not on profits and private marketisation (Caritas Europe). Training and education of caregivers, including informal carers, contribute to enhancing the quality of care provided. This could also be achieved by integrating home care programmes into professional healthcare training (Caritas Europe). In addition to this, early childhood education and care staff should be properly trained and equipped in order to facilitate inclusion, gender equality and end segregation of Roma children (EASPD and ERGO). Furthermore, certified child minders would improve the quality standards of early childhood education and care (COFACE). Quality not only ensures the dignity of persons receiving care, but also increases trust in care services. Employers stressed the importance of an outcomes-based approach to investment (e.g. by integrating quality criteria in public procurement) and called for quality regulation to apply in the same way to public and private actors (BusinessEurope). 3.7 Care workers

Transformative care policies are needed. A decent work approach to the care economy should be incorporated in the European Care Strategy which is grounded in the ILO’s Decent Work Agenda, the UN’s Agenda 2030 and its Sustainable Development Goals. The elements of ILO’s 5R Framework for Decent Care Work are (i) recognize, reduce and redistribute unpaid care work; (ii) reward paid care work, by promoting more and decent work for care workers; and (iii) guaranteeing care workers’ representation, social dialogue and collective bargaining rights. Such transformative care policies can yield positive health, economic and gender equality outcomes (ILO). There is an urgent need to improve the working conditions of the care workforce (EWL, FES/FEPS,). Member States (e.g. DE, FR) are aware of workforce shortages and some are developing strategies to attract more workers, including men, to the care sector. Raising wages as well as pay transparency (for combatting the gender pay gap) will play a role in making the sector more attractive (NCPE, EWL, VÖWG). The situation of the formal carers is a determinant of the quality of care (REIF). Measures to improve their working conditions, training, health and safety at work will contribute to staff attraction and staff retention (CESI, EPSU). All employment regulations, including the ‘Working Time Directive’ and proposed Directive on adequate minimum wages should be correctly and fully implemented for the benefit of all care workers, including domestic workers (LaStrada et al). Labour standards should be guaranteed to all workers in the sector, regardless of their migration or residence status, work arrangements (live-in, live-out, single or multiple employers), employment relationship (placement agencies, provider organisations, contract with the end-users or domestic workers operating as self-employed) (LaStrada et al). It is equally important to provide information and effective complaint mechanisms that enable workers to know their rights, file a complaint and access remedies without any immigration enforcement consequences (LaStrada et al). Moreover, better work-life balance is key (EASPD). Enhancing occupational health and safety (e.g. personal protective equipment, proper risk assessments) is also key for improving working conditions in the care sector (EPSU). The PHS workers as a part of the care workforce should receive policy attention (EFSI). Moreover, safe staffing ratios should be ensured both in early childhood education and care and long-term care (SOS Children’s Villages). Migrant workers deserve more policy attention. There is a need for schemes for regularisation of migrant workers currently performing care jobs with irregular or precarious status (La Strada et al). The recognition of mobile EU and non-EU migrant care workers in factual employment relationships for the purpose of labour rights and social protection (LaStrada et al) should be facilitated. In addition, domestic, home and community-based care work should be eligible under general work permit schemes for admission for people from outside of the EU, as the permits should be renewable for a reasonable period (e.g. two years) (LaStrada et al). Work permits for foreign graduates should also be facilitated (Wirtschaftskammer Österreich). Migrant workers should have the right to bring family members (LaStrada et al). Regulating European cross-border placement agencies for care workers and ensuring the application of all relevant legal provisions and decent work standards is important to prevent abuse (FES/FEPS). Yet, some respondents suggest that welfare measures that promote domestic care work and other precarious care schemes should be avoided (FES/FEPS). Live-in carers in many countries operate in the “grey” economy, which deprives them from social and legal protection (SSE). Moreover, heavy reliance on staff from other countries is noted to be an unsustainable option, since carers might return to their home countries at some point (SSE). On the other hand, if they do not return, the long-term negative effects of migration of care workers from less developed regions to more developed ones, might create a situation where the access to care services of the aging population from these less developed regions is gravely affected by the severe staff shortages (Harghita County Council). The imbalances between the destination countries and countries of origin of care workers within the EU, and the needs of the workers themselves are to be taken into account (FES and FEPS). Retaining and attracting trained and qualified staff is increasingly challenging. (SSE, DSV). New recruitment and training strategies need to be developed (SSE). Skill gaps and needs, good practices, and successful initiatives should be identified (SSE, Eurodiaconia). Member States highlighted the need for the professionalisation of the care sector, the role of training and qualifications (DE and EE in SPC) and the prospects of care as a potential career path for young people (FR in EMCO). Care workers should have access to customised professional training and professional development (NCPE). Recognition and certification of social, technical, linguistic and transcultural competencies and skills acquired, including for informal carers (LaStrada et al) should be facilitated. Upskilling and reskilling is also of paramount importance (CECOP, SSE, Eurodiaconia, LaStrada et al). It is critical to create a modern, positive, professional and career-based image of the sector (EAN). Especially for the revalorisation of the work in early childhood education and care, training and reskilling the workforce and work on the gender aspect is important (COFACE). Staff should be offered opportunities to boost their inclusive skills and to access trainings on discrimination and unconscious bias (COFACE). Attracting young workforce could be facilitated by campaigns among the youth (Harghita County Council). This could be reinforced also through developing jobs and professions in the care sector that have much broader skill sets than those that currently exist (LaStrada et al). Increasing the variety of training paths and expanding tasks, financial support and incentives during training is also recommended (Wirtschaftskammer Österreich). Member States should provide publicly subsidised opportunities for all carers, including migrant informal carers and care workers, to participate in vocational education and training and gain qualifications. (LaStrada et al). Social dialogue at European and national level and building the capacity of social partners at national level to engage in collective bargaining are of utmost importance. Employers stress the role of the social dialogue and recalled the calls they made for two advisory committees on employment and social policies (BusinessEurope). Trade unions refer to the upcoming social dialogue initiative, including for sectoral social dialogue; they proposed to invite Member States to have a designated contact point for expanding unionisation in the care sector at national level (UNICARE). Trade unions mentioned the importance of adequate staffing levels to ensure quality and person-centred delivery (EPSU) and stressed that migrant workers, domestic workers and people in the personal household services should benefit of the same social and labour rights as workers in the mainstream care sector (EFFAT). Finally, trade unions call for the ratification of the ILO Convention on domestic workers by the Member States and for a revision of the OSHA framework to include domestic workers (EFFAT). 3.8 Informal carers The social value of informal carers’ work is largely unrecognised across Europe and the world. However, the European care strategy can play an important role to address this. Apart from being fair and justified, adequately recognising and supporting informal carers will address care quality, safety and sustainability (IFIC). Access to information, training, counselling and access to complementary care services should be put in place (LaStrada et al, Incare). Particular attention should be paid to defining a legal status for informal carers, facilitating access to rights such as employment rights, social protection, respite care, financial support, pension credits, and flexible working arrangements (Red Cross, Eurocarers, AIM, ESN). Moreover, it is crucial to ensure relief for informal carers, including targeted relief services (e.g. respite care, holiday care) and the extension of existing services (e.g. longer opening hours of day centres, provision of mobile services also during the night) (VÖWG, Vienna Social Fund). Besides, more flexibility is called for in the exercise of carers’ rights in cross-border situations (AIM). Member States should also develop measures to provide specific support to informal carers of migrant origin (LaStrada et al). Parents and caregivers should be able to enjoy a proper work-life balance and they should have flexibility to spend adequate quality time with their children (ERGO and COFACE). Better recognition of the role of informal carers, including families is needed (Federation of Catholic Family Associations in Europe). Recognition of their status and improvement of their situation (with a right to respite and simplified procedures for access to rights, for example) are key to the success of any initiative in this area (REIF, AIM, EASPD). Other policy measures may include increasing the non-taxable income threshold for carers as well as increasing the ceiling on the number of hours in paid work outside the home (CAI). Informal care should be recognised through the introduction of care credits to offset breaks from employment taken to provide informal care to family members and periods of formal care leavers (MMM). The importance of incorporating targeted labour market integration measures and promotion of career opportunities for informal carers providing the main part of family care has been stressed (VÖWG). Some respondents insist on recognising and validating the skills acquired while doing unpaid family care work (MMM). Health prevention for informal carers should be provided through mental health support, targeted information, and better communication channels with formal carers (ESIP, DSV, Red Cross, AIM). 3.9 Potential of digitalisation and innovation for the care sector Digitalisation offers substantial opportunities in several aspects in the delivery of long-term care, both for care recipients and carers (EAN, REIF). For example, investing in more effective information systems would simplify administrative procedures and speed up communication between service providers and service recipients. With telemedicine being on the rise, it is suggested that it will become the standard of care for some visits, check-ups and consultations, especially chronic conditions and long-term diseases (Europa Donna). Moreover, digitalisation could enhance the accessibility of care services, especially in remote and rural areas (REIF, ESIP). This could benefit the feasibility of home care as a long-term care option (ESIP). Yet, it is crucial to maintain the complementarity between digital and physical provision of care (REIF, Social Platform). For carers, digitalisation has the potential to improve their working conditions (Social Platform, EAN, ESN). Employing assistive technology and applications can increase care recipient’s independence and reduce the intensity or time of care needed (EAN), which addresses the challenge of staff shortages. Further, digitalisation can make the care jobs more flexible, allowing for a certain degree of remote working (ESN). With the establishment of more and better digital communication tools, care professionals can much more easily collaborate with and support each other (AIM). Digital inequalities and digital divide should be taken into account and tackled (ESIP, Social Platform, AIM, ERGO). Due to a lack of digital skills, a lack of IT infrastructure, lower income or by choice, some persons in need of care cannot make use of digital tools (ESIP). Solutions could also build on EU-funded social innovation projects in long-term care as well as the guidelines on integrated care by the WHO and other stakeholders (Eurocarers). However, current legislation and regulations of services on the internal market as well as unclear classification of health and social services hamper the development of adequate social services in innovative care concept (EAN). Additionally, the blur between health and social care and more commercial services with a social objective is reported to lead to an unnecessary financial and bureaucratic burden for care providers, hindering them to develop their full potential (EAN). Therefore, special attention should be paid to VAT, taxation and regulation in the care sector. Innovation in care has a great potential and should be more heavily promoted. This could take place for example through targeted calls within the Horizon Europe Programme or the European Competence Centres for Social Innovation (EaSI). Financial instruments and investment (e.g. InvestEU) should be utilised by the Care strategy to boost investment into the social sector (SSE, CAP). Additionally, EU funds should become more accessible to care organisations and care service providers – either through raising awareness about the available opportunities for EU funding or through reforming EU funding programmes in a way that social care providers could also qualify to utilise them (EAN). 3.10 Financing of care services

Public funding and investment for the development of the care economy should be viewed as an investment in the future, not merely as a cost (Social Platform, EWL, Eurodiaconia, EPSU). Public funding of care services is being strongly encouraged (SSE, Social Platform, EWL, Eurodiaconia, EPSU, VÖWG, Vienna Social Fund), reflecting the call for a person-centred approach to care, as opposed to a market-centred approach (EPSU). Sustainable public funding is deemed crucial to guarantee the quality, continuity, accessibility, availability, and affordability of social care services for people in need of care (SSE, AT in SPC). Such guarantees are reported to have proven unreliable through the current funding levels, as well as through competition-driven funding instruments (i.e. public procurement) and long-term care insurance (CECOP, SSE, VÖWG, Vienna Social Fund). Member States should be supported to implement the European Child Guarantee to increase public investment for children (PICUM). A voluntary handbook on financing models was proposed (EE in SPC). EU funds and instruments can support national investments and reforms in LTC (EWL, Eurodiaconia, European Disability Forum). Examples include: reforming the fiscal rules of the Stability and Growth Pact to give more flexibility to Member States to invest in care services and care workers (Eurodiaconia); making relevant funds from the Multiannual Financial Framework (MFF) and Next Generation EU accessible to not-for-profit care service providers (Social Platform); investing EU funds in personal assistance and in-home support schemes (European Disability Forum). The need to use the Recovery and Resilience Facility (RRF) for care was echoed by trade unions (ETUC, UNICARE). It is suggested that funding be conditional on providers abiding by safe staffing ratios and good working conditions, (EPSU, Eurodiaconia). Profit made through care provision should be directly reinvested into the sector (Eurodiaconia, VYV). CECOP highlighted the role that the social economy which already reinvest profits to ensure long-term dimension and uninterrupted functioning of the service. Besides, recovery funds should be invested in robust care infrastructure (NCPE). Financing by means of tax resources within Member States remains key, though (Vienna Social Fund). Proper tax incentives could potentially also boost the influx of private finance into the care sector (CAP, Insurance Europe). The use of the ESF+ and the Child Guarantee national action plans to improve access, affordability and quality of care services for vulnerable and disadvantaged people and families, including mobile EU and non-EU migrants (PICUM). EU funding should be conditional upon compliance with worker’s rights and collective bargaining. The award of public funds such as the ESF+ and the national recovery and resilience facility should be made conditional on the respect of workers’ rights and collective bargaining. In cases where the provision of long-term care services is awarded via public procurement contracts, contracts should only be awarded to economic operators or subcontractors who fully respect workers’ right to collective bargaining (UNI Europa). It is important to develop approaches to care that decrease the pressure on health systems (Insurance Europe). These might include: promoting prevention and healthy lifestyles (Insurance Europe); making meaningful use of digital solutions (VÖWG, Vienna Social Fund, Insurance Europe); developing payment and reimbursement systems based on pathways rather than individual and disease specific interventions, aiming to make health and social systems more sustainable (EFN). Supporting Member States in making insurance cover more accessible and affordable (Insurance Europe) is important. Insurers could be keen to explore with authorities the possibility to expand their range of activities, particularly services that encourage prevention, awareness and adaptation – areas, in which insurers have experience and which are vital to keep healthcare costs affordable (Insurance Europe). 3.11 Governance and implementation The European care strategy is expected to position care as a prominent priority at EU and national levels (SSE, Eurocarers). On an EU level a permanent group in the form of an institutionalised platform or a steering group is recommended to be created (AEIP, AIM), or a European Care Platform that would work on a similar basis to the Disability Platform (SSE, Eurodiaconia). On the national level, Member States are encouraged to develop clear national action plans (SSE). Measurable indicators, concrete objectives, and mechanisms for follow-up, including timeframes and indicators play an important role in the effective implementation of the Strategy (EAN, ESN, Eurocarers, Incare, REIF). Development of a coordinated and harmonised data infrastructure and tools for EU-wide comparable data on long-term care across Europe, including EU indicators, quality audits, quality integrated statistics as well as data on attitudes, preferences and expectations on long-term care are called for (Incare, AGE, AEIP, Red Cross). It is also key to social partners to set indicators for policy monitoring (ETUC, NEXEM). As social protection and long-term care systems differ across countries, it is deemed important that the proposal for a Council Recommendation on long-term care focuses on the overarching objectives at EU level (SME United). Consistent monitoring for participation to early childhood education and care should be ensured. Disaggregated data should monitor children including children with disabilities’ participation in early childhood education and care and this analysis should be transformed into policy measures (EASPD). Due regard should be given to the administrative burden at national level. Some Member States (SPC) shared concerns regarding the 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 SPC and EMCO, several Member States (e.g. EE, HU) pointed out that the initiative should be developed in full respect of national competencies and the principles of subsidiarity and proportionality, also taking into account the different national circumstances and set-up of the care systems. EU level support for mutual learning among Member States is appreciated to support implementation efforts. This may include measures to ensure decent work conditions for care workers in private homes through defining and enabling labour inspections in private homes as well as providing opportunities in a safe environment for workers to speak with relevant authorities (LaStrada et al). Member States (SPC and EMCO) also agreed on the need to improve the evidence base and supported a continued exchange of good practices. Facilitating dialogue and exchange of best practices among Member States as well as between service providers and national authorities is also viewed as an integral part of the European care strategy (Red Cross, CAP, ViiV). In the development, monitoring and evaluation of care policy-making, it is crucial to involve representatives of care workers, as well as of care recipients (LaStrada et al). Moreover, it is important that persons in need of care with statutory care insurance are guaranteed the right to freedom of movement through adopting a reform on the Regulations on the coordination of social security systems (DSV). There are strong call for the European care strategy to take an integrated approach to care (EPSU, EMSP, Eurocarers, IFIC, ViiV, EURORDIS, AEIP, ESN, Platform for better oral health in Europe, European Hospital and Healthcare Federation, Santa casa). Facilitation of effective communication as well as collaboration between health and social care professionals (EMSP, EURORDIS, Platform for better oral health in Europe) is needed. Synergies should be established between health and community services, including peer-to-peer support (ViiV). It is recommended that not only a patient’s medical profile is taken into account for long-term care services, but also his/her family, economic and environmental context (AEIP). Development of integrated home and community-based care services is also essential, since the lack of such integration increases reliance on informal care as a default option (Eurocarers). Therefore, investment in community-based care is going to not only increase the quality of care, but also enhance care options and make care jobs more attractive (Eurocarers). Besides, it is emphasised hat local actors play a key role in the long-term care delivery, which is why their recognition and stable financing for innovative long-term care providers is very important. An effective integration of healthcare and long-term care (and within these sectors) has a positive impact on care quality (SE in SPC). The European Semester is considered to be the right framework to monitor progress in addressing challenges in the care sector. Social Partners encourage Member States to use the RRF (ETUC, UNICARE) for care and highlighted that the European Commission can also support preparations for LTC reforms through funding for technical assistance (BusinessEurope). 3.12 Active and healthy ageing and prevention policies Investing in prevention saves lives and reduces costs. In order to tackle increasing demand for LTC brought by the ageing of the population, fostering health promotion, prevention and health literacy across the lifespan is key (ESIP, Eurohealthnet, MGEN, BAGSO). The European Care Strategy is expected to support Member States in developing and implementing guidelines for prevention and empowerment (EFN). Prevention campaigns and health promotion should also reach people with disabilities, including those in institutions, and be accessible to avoid further costs (Inclusion Europe). Screening, early detection and prevention, data registries and electronic health records, as well as health systems reforms are viewed as an important part of the solution (EFPIA). Health promotion and disease prevention activities should address the causes (biological, psychological and social aging), and not the consequences of illness (Red Cross). This helps to reduce, delay or prevent reliance on care (Vienna Social Fund, VÖWG). In particular, eye health checks should be seriously taken into account in public policy – not only due to the obvious difficulties caused by sight loss, but also since issues such as diabetes, hypertension and neurological conditions (e.g. multiple sclerosis or brain tumours) can be detected through visual inspection and without an invasive procedure (ECOO). Rehabilitation and social inclusion of older people in community life are key success factors for active and healthy ageing. Remobilisation measures ensure that people with care needs can stay in their usual environment for as long as possible (DSV, IT in SPC)). Furthermore, activating communities to include older vulnerable people from the neighbourhood and even residents of nursing homes and care homes in community activities helps to keep people socially involved and to make them feel useful, also contributing to reducing loneliness (EAN). Provided that older persons desire to work, self-employment could also have a favourable effect on their perception of feeling useful and independent (VÖWG). For cancer patients and survivors, having the ability to work has been reported to restore a sense of normality and wellbeing, contributing to financial stability too (TBCT). Therefore, the work dimension could be considered in the development and implementation of long-term care programmes (TBCT). These actions need to be complemented by improved health literacy and adherence to treatment of the population, as this will contribute to better health outcomes and more efficient use of health resources (EFPIA). A holistic approach to ageing for improving the quality of life at all stages, strengthening healthy and active ageing policies, and promoting lifelong learning needed to stay at the centre of policy attention (Red Cross). 3.13 The impact of the COVID-19 pandemic Enhancing the resilience of care systems is crucial. The COVID-19 pandemic has exposed the care systems across the Union to be largely unprepared for care emergencies. Better preparedness for future crises should be ensured (AIM, EPSU). Guidance for professions at risk should be proposed on how to ensure proper working conditions (AIM). Such a guidance should be developed in collaboration with networks of care professionals and implemented with the help of financial and technical support to Member States (AIM). Furthermore, Member States should ensure that their health and care systems are more resilient through reinforcement of medical workforce and equipment, the implementation of concrete measures for the provision of care and enhancing capabilities for virtual health and care administration (EURORDIS). Public funding for long-term care should be regarded as an investment in community health and welfare (EPSU). Monitoring of LTC policies at Union level, for instance through a uniform system of surveillance for long-term care that monitors pandemic outbreaks in long-term care across the EU Member States (EPSU), may be helpful. Long-term care should also be included in the stress-tests set out in EU regulation on serious cross-border threats (EPSU).