Opinion of the European Economic and Social Committee on Guaranteeing universal access to long-term care and the financial sustainability of long-term care systems for older people
Date: 2008-03-13
Institutions: European Economic and Social Committee
Subjects: dependence of elderly persons, elderly person, health care, health care system, health costs, health policy

9.8.2008

EN

Official Journal of the European Union

C 204/103

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

(2008/C 204/21)

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

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

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

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

1. Conclusions and recommendations

1.1 Conclusions

which
responses as well as policy measures (2).

appropriate

require

information

and

educational

1.1.5
The ultimate objective must be to make it possible for
old and very old people in Europe to live their lives safely and
with dignity, even if they are dependent on care, while at the
same time ensuring that
impose unbearable
burdens on the younger generations.

this does not

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

1.2 Recommendations

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

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

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

1.1.4
As in the health care system, the bulk of the costs of
long-term care arise in the last years of a person's life. Since
current
(health care and pensions
systems) were established, life expectancy has increased consid-
erably. Facing up to the resulting new needs requires tackling
justice and solidarity,
intergenerational
difficult questions of

security systems

social

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

1.2.2
In order to do justice to the challenges of long-term
care, a number of measures are needed. Some key aspects of
this are the following:

Financing and affordability

— universal access to high-quality care must also be guaranteed
in practice for people with particular problems or low
incomes;

— sustainable financing systems must be developed which do
leave individuals to face this risk alone, while also
not
ensuring that society can afford such services without
placing an undue burden on future generations;

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

C 204/104

EN

Official Journal of the European Union

9.8.2008

— the promotion of preventive measures should help to miti-
gate the rise in demand as far as possible. This will require a
comprehensive preventive strategy bringing together aspects
financial provision,
of health-related preventive measures,
social provision and measures to boost older people's ability
to cope with everyday problems;

working conditions for care workers and by upgrading the
caring professions;

— the recognition of qualifications throughout the EU should

be facilitated;

— incentives — e.g.

tax incentives — for private financial
provision should be considered when it appears necessary to
achieve the general interest objective of public health.

— the Commission is asked to review the arrangements for
cross-border aspects of care, such as access to care services
abroad and the migration of care workers;

Care and supply of services

— the development of tailored care services geared to needs
must also be ensured in regions which are currently disad-
vantaged in this respect;

— existing

family

and neighbourhood networks, which
currently provide the bulk of care, must be encouraged and
strengthened, e.g.
family
members;

training of and support

for

— NGOs, social economy initiatives and cooperative structures

should be involved to a greater extent in care work;

— special encouragement should be given to volunteering in
the non-medical care sector, especially in the form of
training for volunteers;

— healthy competition between different suppliers of care
services should give care recipients more freedom of choice
and help develop the supply of services in accordance with
defined quality standards, objectives, tasks, specifications and
an established social security system, under the responsibility
of the legislator in each Member State, since these services
fall within the scope of social services of general interest (3);

— older people and those in need of care must be included to
inter alia in order to

a greater extent in social networks,
prevent abuse and ill-treatment;

— best-practice models should be developed in palliative care

in nursing homes and in home care;

— in order to prevent work being performed in the black
economy, measures must be adopted to bring hitherto illeg-
ally provided care services into the framework of a legal
employment relationship,
the specific
features of work performed in private households.

taking account of

Care in the family

— there should be greater incentives for providing non-medical
care services, either within the family or on a voluntary
basis (4);

— strategies and services must be developed to address the
problems of dementia and depression in older people, which
are among the main challenges facing families and the care
system;

— it should be made easier to reconcile family and career
through support and respite measures for working family
carers (e.g. day-care facilities for older people in large
companies, respite services, mobile care).

Rules, standards and quality

— quality standards should be developed for all areas of care of
older people and effectively monitored by independent orga-
nisations or
supervisory authorities and recognised by
human rights institutions;

— in this way it should also be ensured that human rights and
dignity are protected in both public and private care homes
and that the limited capacity to act and dependence on
services of those in need of care are not used to their disad-
vantage.

— hospice work should be developed.

Use of information and communication technologies

Care workers

— the human resources must be provided for care services, in
particular by providing high-quality training and improved

— the use of information and communication technologies,
telematics and technical aids should be encouraged in care
work and for monitoring purposes, with due attention to
ethical issues.

(3) See the EESC opinion of 14.2.2008 on Services of general

interest

(rapporteur: Mr Hencks) (TEN/289).

(4) On the promotion of volunteering,

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

9.8.2008

EN

Official Journal of the European Union

C 204/105

2. Background

relation to the use of this method, the EESC attaches the highest
importance to the involvement of the social partners and civil
society players.

In some places,

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

3.3
The reports drawn up by individual states in this connec-
tion show that, despite differing starting situations and condi-
tions, many challenges are similar in most countries. A coopera-
tive approach to seeking solutions would therefore make sense.

The objectives

jointly agreed at EU level

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

2.2
The Slovenian presidency intends to hold a conference
(28/29 April 2008) on solidarity and co-existence between the
generations, which will focus on:

4. The demographic and social background

1) solidarity between the generations on health care, family life

and house building;

2) long-term care for older people.

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

3. Long-term care as a European challenge

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

3.2
The European institutions have — without prejudice to
national competences — launched numerous initiatives (5) on
the subject and have in particular promoted the reciprocal
exchange of experience using the open method of coordina-
tion (6). These efforts should be continued and stepped up; in

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

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

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

their numbers are forecast

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

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

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

4.5
As a result of the low birth rate (in 1960 almost all EU
states were above the replacement fertility rate of 2.1, whereas
in 2003 all the EU states were below it) not only will the poten-
tial for intergenerational support (relationship between those

(7) Commission Communication — Green Paper — Confronting demo-
graphic change: a new solidarity between the generations 16.3.2005, COM
(2005) 94 final.

C 204/106

EN

Official Journal of the European Union

9.8.2008

needing care and potential carers) — and thus the potential for
family care — decline, but it will also become increasingly diffi-
cult to meet the demand for professional carers on the labour
market. Moreover, this trend will exacerbate the problem of
financing long-term care.

must undergo training that leads to a qualification, providing
their services in older person's own home or in specialised insti-
tutions.

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

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

An important challenge is

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

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

5. Ensuring access to tailored care service

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

5.2
For the reasons outlined above family members cannot
in future he expected to be available for the provision of care to
the same extent as in the past. A rising number of frail older
people will therefore be dependent on professional carers, who

(8) See EESC opinion of 14.3.2007 on The family and demographic change,

rapporteur: Mr Buffetaut (OJ C 161, 13.7.2007).

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

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

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

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

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

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

9.8.2008

EN

Official Journal of the European Union

C 204/107

6. Financing care systems

— the increased use of technical aids in care work and the use
of information and communication technologies (e.g. smart
housing, distance monitoring and older people learning to
communicate via IT tools).

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

7. Quality of long-term care

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

6.3
The key question with regard to the long-term financing
of care is: how can rising costs in this area be contained?
Possible measures and strategies are listed below:

— maintenance and strengthening of family care, in particular
through incentive mechanisms and respite services (e.g.
short-term care, holiday care, day-care facilities);

— ongoing development and improvement of the supply of
care services, e.g. with regard to choice, cost, quality and
efficiency;

People in need of help also have a right

7.1
to service
quality. To this end the European Union has set the objective of
ensuring access to high-quality and sustainable care (9).

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

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

and regional

— establishment of competitive structures (where possible and
to encourage cost-awareness and

appropriate),
in order
development by means of competition;

8. The long-term care labour market

— a comprehensive preventive strategy., This should range
from preventive health measures and the prevention of acci-
dents (e.g. falls in the home) via private financial provision
to the development of new social networks in old age which
can provide support services, and boosting older people's
ability to cope with everyday problems (e.g. ability to run
the household);

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

— increased involvement of volunteers in care services (e.g.
neighbourhood schemes, visiting and mobility services, assis-
tance with care, hospice care), including cross-generational
discussions with schoolchildren and young people;

8.2
The care sector offers opportunities to groups which
often experience difficulties finding employment (e.g. people
immigrants). The EESC suggests
rejoining the labour market,

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

2013.

C 204/108

EN

Official Journal of the European Union

9.8.2008

that this fact be reflected in the programmes of the national
employment agencies as well as in the European employment
programs (retraining, skills acquisition).

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

employer/employee

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

in these

involved

should

also

be

the European Union and its impact on families. Demographic
trends mean that in future more people will have to look after
elderly relatives while also working. The development of care
services should therefore also be seen as a way of lightening the
burden on family carers and possibly making it easier to recon-
cile career and care obligations.

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

10. Hospice work and dying with dignity

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

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

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

11. Care and abuse

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

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

9. Reconciling care, family and career

In its opinion entitled The

9.1
family and demographic
change (10) the EESC looked in detail at demographic change in

(10) See the EESC exploratory opinion on The family and demographic change

of 14.3.2007, rapporteur Mr Buffetaut (OJ C 161, 13.7.2007).

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

12. Exchange of experience through open coordination,

research projects and additional activities

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

In an earlier opinion (15)

12.2
the EESC suggested which
subjects should be the focus of analysis and exchange of experi-
ence.

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

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

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

(14) See EESC exploratory opinion on Elder abuse of 24.10.2007, rappor-

teur: Ms Heinisch (SOC/279 — CESE 1465/2007).

(15) See footnote 3.

9.8.2008

EN

Official Journal of the European Union

C 204/109

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

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

12.5
OECD and the WHO should also be encouraged.

Cooperation with international organisations like the

13. European law

13.1
Although long-term care does not fall directly under
the remit of European law, it is significantly influenced by it via

other areas of the law. While the consequences of the Directive
on services in the internal market, especially for social services
of general interest, are unclear, the Court of Justice nevertheless
interprets the freedom to provide services strictly (*). Service
providers and their employees and people receiving long-term
care may find themselves in situations of
legal uncertainty
although the need for this type of care will increase throughout
the EU. There will be considerable disparities in supply and cost
between Member States, which, at least in border areas, may
well result in a rise in the already-established phenomenon of
medical tourism and poses major problems for the local autho-
rities concerned. The impact on long-term care should therefore
be considered when these areas of the law are being developed.

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

Brussels, 13 March 2008.

The President

of the European Economic and Social Committee

Dimitris DIMITRIADIS

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

(*) Judgment of the ECJ C-341/05 of 18.12.2007 (Laval un Partneri Ltd v.

Svenska Byggnadsarbetareförbundet et alii).