COMMISSION STAFF WORKING DOCUMENT Long-term care in ageing societies - Challenges and policy options Accompanying the document COMMUNICATION FROM THE COMMISSION TO THE EUROPEAN PARLIAMENT, THE COUNCIL, THE EUROPEAN ECONOMIC AND SOCIAL COMMITTEE AND THE COMMITTEE OF THE REGIONS Towards Social Investment for Growth and Cohesion – including implementing the European Social Fund 2014-2020
Date: 2013-02-20
Institutions: European Commission
Subjects: care allowance, elderly person, health care, population forecast, population statistics, social assistance, social cost

EUROPEAN 
COMMISSION 

Brussels, 20.2.2013  
SWD(2013) 41 final 

Social Investment Package 

COMMISSION STAFF WORKING DOCUMENT 

Long-term care in ageing societies - Challenges and policy options 

Accompanying the document 

COMMUNICATION FROM THE COMMISSION TO THE EUROPEAN 
PARLIAMENT, THE COUNCIL, THE EUROPEAN ECONOMIC AND SOCIAL 
COMMITTEE AND THE COMMITTEE OF THE REGIONS 

Towards Social Investment for Growth and Cohesion – including implementing the 
European Social Fund 2014-2020 

{COM(2013) 83 final} 
{SWD(2013) 38 final} 
{SWD(2013) 39 final} 
{SWD(2013) 40 final} 
{SWD(2013) 42 final} 
{SWD(2013) 43 final} 
{SWD(2013) 44 final}

EN 

   EN 

 
 
 
 
  
 
COMMISSION STAFF WORKING DOCUMENT 

Long-term care in ageing societies - Challenges and policy options 

Accompanying the document 

COMMUNICATION FROM THE COMMISSION TO THE EUROPEAN 
PARLIAMENT, THE COUNCIL, THE EUROPEAN ECONOMIC AND SOCIAL 
COMMITTEE AND THE COMMITTEE OF THE REGIONS 

Towards Social Investment for Growth and Cohesion – including implementing the 
European Social Fund 2014-2020 

Contents 

1. 

2. 

2.1. 

2.2. 

2.3. 

3. 

3.1. 

3.2. 

3.3. 

Introduction .................................................................................................................. 3 

Expected growth in long-term care needs.................................................................... 5 

Demography................................................................................................................. 5 

Dependency levels — developments in health status .................................................. 6 

Conditions influencing the capacity for independent living ........................................ 7 

Present supply of LTC in the EU under different financing and delivery models....... 8 

Considerable differences in LTC provision ................................................................. 8 

Data on current LTC provision .................................................................................... 9 

Composition of LTC provision .................................................................................. 11 

3.3.1.  Mix and cost of formal and informal care.................................................................. 11 

3.3.2. 

Informal care .............................................................................................................. 11 

3.3.3.  The public-private mix in the delivery and financing of formal care ........................ 12 

3.3.4. 

In-kind services versus vouchers or cash benefits ..................................................... 12 

3.3.5.  Use of undeclared care and immigrant carers ............................................................ 12 

3.4. 

3.5. 

4. 

4.1. 

4.2. 

4.3. 

4.4. 

Typology of LTC provision in the EU27................................................................... 12 

Typology of LTC systems in the EU27: Spatial map and legend.............................. 13 

Relative strengths and limitations of different delivery models ................................ 14 

Leaving it to families to provide informal care for their ageing kin.......................... 14 

Getting families and households to pay out of pocket for their informal care needs. 15 

Providing support to family carers............................................................................. 15 

Replacing informal with formal care in various models of LTC financing & delivery
.................................................................................................................................... 16 

4.4.1.  Publicly financed public provision............................................................................. 16 

4.4.2.  Social-insurance funded care, delivered by private non-profit or for-profit providers

.................................................................................................................................... 16 

EN 

1 

   EN 

4.5. 

5. 

5.1. 

5.2. 

5.3. 

6. 

6.1. 

6.2. 

6.3. 

6.4. 

6.5. 

7. 

7.1. 

7.2. 

7.3. 

7.4. 

7.5. 

7.6. 

8. 

9. 

In sum......................................................................................................................... 17 

Policy options for addressing future LTC challenges ................................................ 17 

The overall challenge in LTC .................................................................................... 17 

The challenge for public budgets ............................................................................... 17 

Policy responses needed to tackle the challenges ...................................................... 18 

Good practices in Member States applying social investment approaches to LTC... 20 

Comprehensive national approaches.......................................................................... 20 

Prevention .................................................................................................................. 20 

Rehabilitation ............................................................................................................. 21 

Productivity and capacity gains from innovation, including through use of ICT...... 21 

Quality assurance ....................................................................................................... 21 

Contributions from Europe ........................................................................................ 22 

Prevention .................................................................................................................. 22 

Productivity and capacity gains from innovation including through use of ICT....... 23 

The European Innovation Partnership Pilot on Active and Healthy Ageing (EIP 
AHA).......................................................................................................................... 23 

Quality assurance ....................................................................................................... 23 

Public finances and research ...................................................................................... 25 

Possible follow-up actions ......................................................................................... 26 

Conclusion.................................................................................................................. 27 

Annex ......................................................................................................................... 29 

9.1. 

Productivity and capacity gains from innovation including through use of ICT....... 30 

EN 

2 

   EN 

 
 
1. 

INTRODUCTION 

This Commission Staff Working Document, which is part of the Social Investment Package, 
deals with social protection against the long-term care (LTC) risks that affect women and men 
if they develop frailties or contract multi-morbidities as they age1. 

As one of the annexes addressing how social investment at different stages of life can ensure 
better outcomes at lower or similar levels of cost and staffing, this document also links to the 
annexes on Investing in Health and on Social Services of General Interest. 

It  demonstrates  that  even  late  in  life  there  are  strong  arguments  for  a  social  investment 
approach  to  social  protection.  If  Member  States  where  the  number  of  very  old  people  will 
triple  in  the  coming  decades  are  to  be  able  to  offer  sufficient  social  protection  against  LTC 
risks they will need to find ways to contain the growth in the demand for LTC provision while 
also  raising  the  efficiency  of  care  provision.  Thus,  arguments  focus  on  the  economic  and 
social  returns  that  a  determined  strategy  of  social  investment  can  achieve  through  a 
combination  of  reduced  disability  in  old  age,  improved  capacity  of  older  people  to  manage 
functional limitations and higher productivity in care delivery. 
In line with the Guiding Principles on Active Ageing adopted by the Council2, this document 
follows up the focus on independent living in the EY2012 on Active Ageing3. Moreover, in 
support  of  the  objectives  of  Europe20204,  it  suggests  how  one  of  the  key  challenges  of 
population ageing may be addressed. 

Across the European Union, long-term care for older people refers to a range of services and 
assistance for persons who over an extended period of time are dependent on help with basic 
activities  of  daily  living  (ADLs)5  and/or  instrumental  activities  of  daily  living  (IADLs)6.  In 
Member States with extensive provision, social protection against LTC risks also increasingly 
includes measures that help prevent, postpone or mitigate the onset of LTC needs. 

It is estimated that one in two women and one in three men will come to need intensive long-
term  care  as  they  age.  The  need  for  long-term  care  arises  as  a  result  of  disability,  which  is 
usually due to health problems. But long-term care is organised and financed differently from 
acute health care in all Member States. Whereas health care is almost exclusively dispensed 
by  health  care  professionals,  a  substantial  part  of  LTC  services  is  provided  by  untrained 
informal family carers. Therefore, it makes sense to view LTC provision as a combination of 
informal and formal care. Moreover, since social services such as home help are an integral 
part  of  formal  LTC  services  and  benefits,  they  also  involve  a  skill-mix  in  staffing  which 
differs from health care. 

Long-term care is a highly gendered issue. Older women have a higher life expectancy and a 
different pattern of morbidity in old age, so most care recipients are women (both in home and 

1  

2  
3  
4  
5  

6  

LTC provision for children and working-age adults with physical and mental disabilities falls outside 
the  scope  of  this  analysis.  The  focus  is  on  the  probability  that  older  people  will  need  LTC  and  on 
population ageing, which is likely to lead to a strong increase in the size of those older age-groups at 
particular risk. 
See: http://ec.europa.eu/social/main.jsp?langId=en&catId=89&newsId=1743&furtherNews=yes. 
See: http://europa.eu/ey2012/. 
See: http://ec.europa.eu/europe2020/index_en.htm. 
ADLs: Activities of Daily Living are self-care activities that a person must perform every day such as 
bathing,  dressing,  eating,  getting  in  and  out  of  bed  or  a  chair,  moving  around,  using  the  toilet,  and 
controlling bladder and bowel functions. 
IADLs:  Instrumental  activities  of  daily  living  are  activities  related  to  independent  living  and  include 
preparing meals, managing money, shopping for groceries or personal items, performing light or heavy 
housework, and using a telephone. 

EN 

3 

   EN 

                                                 
institutional  care  services)7.  Moreover,  the  vast  majority  of  both  informal  and  formal  carers 
are women8. 

As  a  strand  of  social  protection,  long-term  care  provision  is  a  Member  State  responsibility. 
While EU countries set their own level of ambition in LTC provision, they have also agreed a 
set  of  common  objectives  centred  on  access  for  all  to  financially  sustainable,  high-quality 
long-term care. These guide collaboration on LTC issues in the Social Protection Committee. 

Differences between Member States in providing long-term care are more pronounced than in 
any  other  field  of  social  protection.  While  this  can  make  EU  policy  coordination  more 
complicated,  it  also  increases  the  potential  benefits  of  EU-level  collaboration.  Given  that 
Member States are at very different stages in their efforts to address the need for long-term 
care services, Europe could potentially add significant value by pooling the cost of research 
and development and by facilitating knowledge transfer and mutual learning on better ways of 
mitigating dependency and delivering LTC services. 

Population  ageing  is  the  key  common  challenge  in  this  field  for  Member  States  in  the 
medium-  to  longer-term  perspective.  Over  the  next  five  decades,  the  number  of  Europeans 
aged  80+,  and  at  particular  risk  of  developing  a  need  for  LTC,  is  set  to  triple.  In  the  same 
period  the  reservoir  of  potential  formal  and  informal  carers  will  reduce  significantly  as  the 
working-age  population  will  shrink,  the  number  of  women  employed  grow,  retirement  ages 
rise and family and living arrangements change. Given that formal LTC provision tends to be 
underdeveloped in several Member States at present and that Member States with extensive 
long-term  care  services  already  find  it  difficult  to  meet  the  demand,  these  prospects  are 
daunting. Unless new, more effective ways of addressing the care needs of older persons are 
developed, long-term care services will be overwhelmed, and a huge gap will open between 
LTC needs and the ability of social protection systems to meet them. 

This paper examines how long-term care needs may develop given the trends in demography 
and  health.  It  describes  the  diversity  of  LTC  provision  across  the  EU  and  discusses  the 
strengths  and  limits  of  present  LTC  approaches  from  a  social  protection  perspective  and  in 
view of future challenges. It then analyses policies and gives examples of good practices that 
could  help  Member  States  meet  the  challenges  and  provide  better  protection  against  LTC 
risks. 

It finds that there is a need for a longer-term strategy of social investment combining policies 
of 

(1) prevention, health promotion and rehabilitation with 

(2) systematic productivity drives in care delivery and 

(3) measures that raise the capacity of frail older people to manage self-care and independent 
living. 

It examines the extent to which such practices are already successfully emerging and whether 
Europe can help Member States with the further development and dissemination of policies of 
this sort. 

7  

8  

Hubert  M.  et  al.  (2009)  Facts  and  Figures on Long-term  Care:  Europe and North  America,  European 
Centre for Social Welfare Policy and Research. 
Ibid. 

EN 

4 

   EN 

                                                 
2. 

EXPECTED GROWTH IN LONG-TERM CARE NEEDS 

The  scale  of  future  needs  for  long-term  care  services  among  older  women  and  men  will 
depend on three factors: 

• 

• 

• 

the number of people in the age group 80+, those most likely to need LTC; 

long-term  care  needs  as  a  function  of  average  health  status,  i.e.  the  extent  to  which 
older people, as they age, are likely to grow frail and develop multi-morbidities;  

the degree to which older people can manage independent lives in spite of functional 
limitations. 

The  number  of  people  aged  80+  can  be  forecast  with  considerable  certainty  and  is  a  given. 
Policy makers may influence the two other determinants, particularly in the medium to longer 
term. 

The average health status in old age will result from health determinants in individuals’ prior 
lives,  including  their  health  behaviours  and  living  conditions  as  they  age,  as  well  as  from 
effective medical treatments that preserve or restore physical and mental functions. 

Their  ability  to  live  independently  will  depend  on  the  age-friendliness  of  environments  and 
living  arrangements  and  on  access  to  assistive  technologies.  Thus  public  policies  need  to 
focus not only on how to meet long-term care needs, as seemingly dictated by demography, 
but should adopt a more preventive stance, seeking to minimise the need for LTC services. 

2.1. 

Demography 

People tend to live longer, and the baby-boom cohorts are joining the ranks of the elderly. As 
a  result  the  number  of  Europeans  aged  80+  is  set  to  rise  particularly  fast.  This  so-called 
‘ageing of the old’ will be especially pronounced from 2030 to 2040. Between now and 2060, 
the number of people over 80 is expected to almost triple. 

Development in number of people 65+ and 80 + in EU27, 2008-2060, millions 

EU27

2008

2010

2020

2030

2040

2050

2060

%  change 
2008-2060

65+
84,6
Of which: 80+ 21,8
Source: 2010 EUROPOP 

87
23,3

103,7
29,7

123,5
36,6

143,1
48,8

149,9
57,5

152,7
62,2

80,50%
185,40%

Meanwhile, according to the 2012 Ageing Report9, the EU27’s population of working age is 
expected to decline by 14.2 % (2010-2060). Thus, EU Member States cannot rely on a general 
increase in labour supply to meet the growth in long-term care needs that could result from a 
tripling  of  the  number  of  people  aged  80+.  Even  if  more  people  are  recruited  into  the 
workforce, there will be such competition for manpower that it will be very difficult to attract 
enough extra staff to formal long-term care to match growing needs. Moreover, the potential 
reservoir of informal carers, mainly spouses and daughters or daughters-in-law10, will also be 
affected by strong structural trends. With the changes in the structure of families and growth 
in  female  employment  rates  as  well  as  higher  pensionable  ages  and  later  retirement  for 
women, the availability of informal carers will be limited. 

9  

10  

European Commission (DG ECFIN) — Economic Policy Committee (AWG), 2012, ‘The 2012 Ageing 
Report — Economic and budgetary projections for the 27 EU Member States (2010-2060)’, European 
Economy No 2/2012. 
Hubert  M.  et  al.  (2009)  Facts  and  Figures on Long-term  Care:  Europe and North  America,  European 
Centre for Social Welfare Policy and Research. 

EN 

5 

   EN 

 
 
                                                 
2.2. 

Dependency levels — developments in health status 

The  increase  in  life  expectancy  has  been  accompanied  by  an  increase  in  the  occurrence  of 
chronic diseases that can limit the ability to handle some daily activities. Thus, the need for 
long-term  care  does  not  arise  from  ageing  itself,  but  is  rather  the  consequence  of  the 
prevalence of frailty and multi-morbidity and the degree to which this causes individuals to be 
dependent  on  others  for  assistance  with  basic  and/or  instrumental  activities  in  daily  living 
(ADLs, IADLs). 

There  is  an  on-going  debate  on  whether  higher  life  expectancy  increases  the  likelihood  of 
functional  impairments.  Looking  at  recent  trends  in  severe  disability,  the  evidence  is 
inconclusive: while data for a number of EU countries showed clear reductions from the early 
1990s to the early 2000s11, for other countries, severe disability among older people seemed 
to have increased12. Moreover, different data sets found opposite trends (decline in Denmark, 
Finland, Italy and the Netherlands; an increase in Belgium and Sweden; and mixed evidence 
in France and the UK)13. 

Indicators  of  healthy  life  years  measure  the  number  of  remaining  years  that  a  person  of  a 
specific  age  can  expect  to  live  without  any  severe  or  moderate  health  problems  or  acquired 
disabilities (Eurostat, 2010). In 2009, men and women in the EU27 at age 65 could expect to 
live more than half of their remaining years with a frailty or disability that could affect their 
ability to manage instrumental and/or self-care activities of daily living. 

He althy life  
e xpe ctancy 
at 65

Life  
e xpe ctancy 
at 65

Pe rcentage  of life 
e xpectancy at 65 
without disability

He althy life 
e xpe ctancy 
at 65

Life  
e xpe ctancy 
at 65

Pe rce ntage  of 
life  e xpectancy 
at 65 without 
disability

EU27

Men

8,4

Men

16,5

Me n

51,0%

Wome n

Wome n

Wome n

8,6

20,1

42,7%

Source:  Eurostat  Statistics  Database;  Joint  Action  European  Health  and  Life  Expectancy  Information  System 
(JA EHLEIS). http://dx.doi.org/10.1787/888932702936 

The key question is whether, as life expectancy increases, dependency levels in old age will 
increase, remain constant or decrease. We do not yet know the extent to which the prevalence 
of disability will be affected over the next decades, as possible changes in health behaviours 
and new treatments take effect.  
For instance, Carol Jagger14 found that with increasing life expectancy in the UK, there will 
be  an  increase  in  disability  prevalence  by  2030.  Other  international  evidence  suggests 
however that the health of older people in the EU will continue to improve. 

11  

12  
13  

14  

Lipszyc, B. et al. (2012), ‘Long-term care: need, use and expenditure in the EU-27’, Economic Papers 
469, November 2012, available at:   
http://ec.europa.eu/economy_finance/publications/economic_paper/2012/ecp469_en.htm. 
Triantafillou J. et al, 2010, Informal care in LTC — European Overview Paper, INTERLINKS report. 
EU-SILC  data  quoted  in  ECFIN  (2012)  Long-term  care:  need,  use  and  expenditure  in  the  EU-27, 
European  Economy.  Economic  Papers.  469  also  show  a  mixed  picture  for  developments  from  2006-
2009. 
MAP 2030 / Carol Jagger — University of Newcastle. 

EN 

6 

   EN 

 
                                                 
Lafortune  and  Balestat15  have  convincingly  argued  that,  although  different  trends  in  severe 
disability  have  been  observed  among  countries,  the  scale  of  the  increase  in  the  number  of 
people over 65 is bound to lead to a rise in the number of severely disabled older people. A 
decline  in  the  prevalence  of  severe  disability  could  mitigate  this  growth,  but  it  will  not 
compensate for the large increase in the number of people in the age groups at risk. 

At  this  stage,  it  seems  safe  to  assume  that  the  ageing  of  the  population  will  lead  to  a 
significant  increase  in  the  number  of  frail  older  people  with  functional  limitations  and 
disabilities. Still, as highlighted above, the need and demand for long-term care is not just a 
function of the prevalence of disability. 

2.3. 

Conditions influencing the capacity for independent living 

The  extent  to  which  physical  and  mental  impairment  means  people  becoming  dependent  is 
influenced by a person’s perception of their ability to manage despite functional limitations. It 
matters a lot whether people are encouraged and enabled to cope. 

The  ability  to  ‘age-in-place’  and  avoid  institutional  care  is  usually  beneficial  for  the  mental 
and physical health of older persons. This is also clearly reflected in people’s preferences. If 
they  develop  a  need  for  long-term  care  in  some  form,  the  overwhelming  majority  of  older 

15  

Lafortune and Balestat (OECD 2007). 

EN 

7 

   EN 

 
 
                                                 
people  would  prefer  to  have  home  help  and  home  care,  enabling  them  to  remain  in  their 
homes16. Four key factors influence the likelihood of this happening: 

•  People’s capacity for independent living is influenced by whether they live alone. The 
availability  of  mutual  support  when  living  with  other  household  members  greatly 
enhances  the  coping  ability  of  frail  people.  If  they  live  on  their  own,  their  need  for 
outside support is more likely to become an issue. Still, much can be done to improve 
their ability to continue to handle most essential aspects of everyday living. 

• 

Improving the age-friendliness of the homes of older persons can play a great part in 
their  ability  to  continue  living  independently  when  they  become  frail  and  develop 
multi-morbidities.  The  ability  to  remain  in  one’s  home  depends  to  a  great  extent  on 
whether  risks  are  addressed,  by  removing  obstacles  and  hazards  in  the  home  and 
installing  facilitating  devices.  Raising  older  people’s  awareness  of  what  they 
themselves can do to take simple measures to avoid accidents and facilitate access can 
greatly improve their ability to cope. 

•  Assistive aids and modern ICT offer promising opportunities to enable older people to 
go on living independently and help informal carers in providing care while preserving 
their  private  and  professional  lives17.  Automated  toilets,  walking  and  lifting  aids, 
power utensils, monitoring and communication tools are among the aids available, and 
there are rapid advances in this field. Developments in standard Home appliances can 
be of immense importance: for instance the widespread use of micro-wave ovens has 
been a great help to frail older people, enabling them to prepare their own hot meals. 
Monitoring  and  reminding  devices  can  provide  support.  Care  can  be  managed 
remotely, helping people to maintain independence safely. Technological devices for 
older  or  disabled  people  are  becoming  available  at  affordable  prices.  They  can  help 
improve cognitive health, reducing isolation and facilitating a wide range of activities 
around the house. Public procurement policies can support such developments. 

•  Access to informal or formal home help and home care services if older people cannot 
quite  manage  on  their  own.  Tailoring  such  support  so  that  it  underpins  a  person’s 
capacity  for  independent  living  is  one  of  the  key  challenges  for  care  providers, 
whether  formal  or  informal.  Carers  can  also  use  many  new  technology  solutions  to 
improve work coordination  and  to  reduce workload and  stress, so  that they can plan 
and use their working time more efficiently. 

3. 

PRESENT SUPPLY OF LTC IN THE EU UNDER DIFFERENT FINANCING AND DELIVERY 
MODELS 

3.1. 

Considerable differences in LTC provision 

The way in which long-term care is  treated in the  social  protection  systems  of  EU  Member 
States  varies  greatly,  notably  in  the  relative  weight  assigned  to  formal  and  informal  care. 
There is also marked diversity in the way formal care is organised (e.g. by public, for-profit 
or  NGO  providers),  financed  (e.g.  via  general  taxation,  obligatory  social  security,  voluntary 

16  
17  

‘Health and long-term care in the European Union’, Special Eurobarometer 283/wave 67.3, Dec. 2007. 
JRC (2013) Can technology -based services support long-term care challenges in home care? Analysis 
of Evidence from Social Innovation Good Practices across the EU: CARICT Project Summary Report. 
Authors: Carretero, S.; Stewart, J.; Centeno, C.; Barbabella, F.; Schmidt, A.; Lamontagne-Godwin, F. 
and Lamura, G. JRC Scientific and Technical Reports Series, EUR 25 695 EN, at: 
http://ipts.jrc.ec.europa.eu/publications/pub.cfm?id=5899. 

EN 

8 

   EN 

                                                 
 
private insurance or out-of-pocket payments) and delivered (e.g. as home care or institutional 
care). 

In all Member States, informal care provided by relatives plays a significant role in the overall 
volume  of  long-term  care  provided.  But  there  is  enormous  variation  in  the  degree  to  which 
affordable formal services have been developed and are made available. 

Formal  LTC  services  may  be  provided  in  a  variety  of  settings,  including  institutions,  from 
traditional  old  people’s  homes  to  modern  nursing  homes,  in  supported  living  arrangements 
(e.g. residential care) or people’s own homes (e.g. home help or home care). Long-term care 
may cover different mixes of health care and social services. 

Several  countries  offer  cash  benefits  or  vouchers  that  can  be  used  to  pay  for  LTC  services 
delivered by professional care providers and, in some cases, by informal carers. In countries 
where  untrained  family  members  can  be  contracted  as  informal  carers  and  receive  an 
allowance  for  the  care  they  provide,  the  distinction  between  informal  and  formal  care  is 
blurred. 

There is no consistency in the legal framework for providing long-term care across the EU. In 
many Member States, extended families are obliged to provide and/or finance care for their 
elderly  relatives.  But  countries  differ  in  the  extent  to  which  they  enforce  this  legal 
responsibility and monitor whether care needs are actually met18. Where formal provisions are 
well-developed, the rules about when people in  need  of long-term  care  have  an  enforceable 
right to certain types and amounts of care are rather dissimilar. 

At one end of a wide spectrum, some Member States (see clusters E and F of the typology of 
European  LTC  systems  in  3.4)  basically  or  primarily  still  rely  on  families  to  tend  to  all  of 
their  elderly  relatives’  needs  for  long-term  care.  Families  cope  either  by  acting  as  informal 
carers themselves, or by arranging external help and financing it out-of-pocket. There is no or 
little pooling of risks across families through formal social protection. 

A large number of Member States (see clusters A, B and C of the typology of European LTC 
systems  in  3.4)  have  developed  some  formal  long-term  care  services  and  secured  at  least 
partial collective financing, either through social insurance schemes or through revenues from 
general taxation. Yet, the accessibility, affordability and quality of these formal LTC services 
differ considerably. 

At  the  other  end  of  the  spectrum,  a  handful  of  countries  (see  cluster  A  of  the  typology  of 
European  LTC  systems  in  3.4)  with  four  decades  of  experience  in  providing  extensive  care 
seek to take comprehensive and integrated approaches to social protection against LTC risks 
in old age. Such approaches include aspects of other public health policies, such as preventive 
measures,  active  and  healthy  ageing,  promoting  autonomy  and  the  capacity  to  live 
independently  through  e.g.  assistive  aids  for  self-care,  provision  of  health  and  social  LTC 
services, and end-of-life or palliative care. 

3.2. 

Data on current LTC provision 

Comparable  data  at  EU27  level  on  the  current  provision  of  formal  and  informal  long-term 
care for elderly people are rather sparse. 
For the purpose of the projections in the 2012 Ageing Report19, the picture of present public 
expenditure for long-term care has been assembled from data agreed by Member States (see 

18  
19  

MISSOC: http://ec.europa.eu/social/main.jsp?langId=en&catId=815. 
European Commission (DG ECFIN) — Economic Policy Committee (AWG), 2012, ‘The 2012 Ageing 
Report — Economic and budgetary projections for the 27 EU Member States (2010-2060). 

EN 

9 

   EN 

                                                 
Figure 1)20. In this scenario-building exercise, informal care is generally viewed as being of 
no direct cost to the public budget, whereas formal provision is understood to involve public 
expenditure, calculated as the sum of publicly financed benefits in kind and in cash for long-
term care purposes. 

Public spending ranges from 4.5 % of GDP in DK to 0.2 % in CY or by more than a factor 20. 
The average for the EU27 is 1.8 % of GDP. SE, NL and DK are high-spending countries, with 
more than twice the EU average of their GDP devoted to long-term care. Five Member States 
spend between 2 % and 2.5 %, seven countries are in the 1-1.5 % range, nine in the 0.5-0.8 % 
span, and the remaining three spend 0.3 % or less. 

Fig. 1 Public expenditure on long-term care as percentage of GDP in 2010, all ages 

Source: based on data from the 2012 Ageing Report. 

These  variations  in  public  expenditure  on  long-term  care  mainly  reflect  differences  in  the 
‘coverage’21 of formal systems of home care and institutional care. The estimates of coverage 
illustrate both the varying extent to which people with care needs receive formal LTC services 
and  differences  in  the  use  of  home  care  and  institutional  care.  Some  countries  report  little 
home  care  and  also  seem  to  have  relatively  limited  ability  to  respond  to  demand  for 
institutional  care.  Some  countries  like  DK,  LT,  NL  and  SE  show  relatively  impressive 
coverage  rates  in  both  types  of  provision  (see  cluster  A  of  the  typology  of  European  LTC 
systems  in  3.4),  while  a  few  rely  predominantly  on  one  or  the  other  (see  cluster  D  of  the 
typology of European LTC systems in 3.4). In 2010, the UK, EL, IE, LU, AT, DE, FR and IT 
seemed  to  rely  relatively  more  on  home  care,  while  institutional  coverage  rates,  though 
moderate overall, were relatively higher in countries like CZ, BG, SI and HU. 

20  

21  

Data  are  from  the  SHA  and/or  ESSPROS  databases  and/or  from  Member  States,  and  are  agreed  by 
Member States. 
In the Ageing Report 2012 a proxy for ‘coverage’ is constructed by calculating the number of recipients 
of formal LTC benefits in cash and in kind reported by Member States as a percentage of people with 
dependency needs as measured by EU-SILC. As people may receive both kinds of benefit, the number 
of recipients may involve some double counting. 

EN 

10 

   EN 

 
                                                 
3.3. 

Composition of LTC provision 

3.3.1.  Mix and cost of formal and informal care 

Public  long-term  care  expenditure  largely  depends  on  how  much  a  country  relies  on  formal 
care. Formal and informal care can be substitutes or complements, depending on the type of 
care  and  needs.  While  formal  care  is  recognised  as  costly,  both  for  the  economy  and  the 
exchequer,  informal  family  care  also  entails  both  opportunity  costs  and  regular  costs  for 
families.  Family  care  involves  costs  for  the  economy  and  the  public  budgets,  as  informal 
carers may not be able to find or stay in formal work, and may thus pay little or nothing in 
taxes  and  social  contributions.  Cost  differences  may  also  relate  to  differences  in  the  quality 
and productivity of informal and formal care delivery. 

Some  countries  (e.g.  in  clusters  E  and  D  of  the  typology)  combine  a  de  facto  emphasis  on 
informal care with a legacy of traditional institutional care, in the form of old people’s nursing 
homes.  Still,  most  of  these  countries  are  transforming  their  nursing  care  models  from 
institutional  to  community-based  care  and  home  care  as  part  of  a  movement  to  de-
institutionalise long-term care. 

3.3.2. 

Informal care 

In most European countries, a large part of LTC for older people is provided by informal care-
givers22.  Even  in  countries  with  a  well-developed  supply  of  formal  LTC,  using  narrow 
definitions of informal carers, the number of informal care-givers is estimated to be at least 
twice as big as the formal care workforce. 

Over 90 % of people providing informal care on a regular basis have a family relationship to 
the  people  they  care  for.  Informal  carers  are  typically  spouses,  middle-aged  daughters  or 
daughters-in-law23.  The  share  of  people  providing  some  care  is  higher  in  northern  Member 
States than in most southern ones. But in the south, informal care involves a larger share of 
heavy care with ADL, whereas help with IADL dominates informal care-giving in the north. 
When  family  carers  only  provide  additional  care,  pressures  may  be  lighter24.  Estimates 
suggest that the economic value of unpaid family care as a percentage of the overall cost of 
long-term care in EU Member States ranges from 50 % to 90 %25. 

Informal carers can be under considerable stress as they try to balance work and family duties, 
and most have received no training in caring for the elderly. Family care can entail substantial 
economic sacrifice, as informal carers may be forced to cut down their working time or leave 
paid employment altogether. Obligations to look after elderly relatives can cause poverty, not 
just while care is being provided, but also later, if care-givers are unable to build up sufficient 
pension rights. 

In northern Europe, being an informal carer is not associated with a significant reduction in 
employment.  This  is  because  of  good  access  to  formal  care  support  and  policies  enabling 
people  to  combine  work  and  family  responsibilities.  In  southern  Europe,  informal  caring 
duties often mean cutting down on paid work, taking only part-time work, or early retirement. 
A  similar  pattern,  though  somewhat  less  pronounced,  is  found  in  some  Member  States  in 
central Europe. 

22  
23  

24  

25  

Triantafillou J. et al, 2010, Informal care in LTC — European Overview Paper, INTERLINKS report. 
Hubert  M.  et  al.  (2009)  Facts  and  Figures on Long-term  Care:  Europe and North  America,  European 
Centre for Social Welfare Policy and Research. 
Hubert M. et al., (2010) Informal carers: the backbone of long-term care, European Centre for Social 
Welfare Policy and Research. 
Triantafillou et al., 2010. 

EN 

11 

   EN 

 
                                                 
3.3.3.  The public-private mix in the delivery and financing of formal care 

Member  States  use  different  combinations  of  financing  and  care  providers.  Long-term  care 
can be organised as part of public health and social services financed by general taxation and 
provided by public sector workers, as in Denmark and Sweden, for instance. It may also be 
organised  primarily  via  compulsory  social  insurance,  as  in  Germany  or  Austria.  Here,  care 
services  are  provided  mainly  by  non-profit  organisations  and  financed  by  direct  payments 
from  the  insurance  authority  or  through  cash  allowances  and  vouchers  for  care  recipients. 
Out-of-pocket private payments are more common for institutional care than for home care. 
For-profit providers have a minor role, though they exist in all Member States, and may play a 
significant  role  in  the  UK.  About  half  of  Member  States  regulate  long-term  care  provision 
mainly  at  national  level,  and  the  rest  share  responsibility  among  central  and  lower-level 
authorities. 

3.3.4. 

In-kind services versus vouchers or cash benefits 

Cash-for-care  benefits  support  individual  choice  regarding  care  received,  while  in-kind 
services  may  facilitate  public  authority  control  over  the  price/quality  ratio.  Cash-for-care 
benefits  are  particularly  prevalent  in  a  number  of  Member  States.  Some  countries  provide 
both in-kind services and cash-for-care benefits. 

3.3.5.  Use of undeclared care and immigrant carers 

The  underdevelopment  of  formal  long-term  care  services  in  southern  Member  States  has 
given rise to the practice of families employing immigrants — including some without legal 
status — as undeclared live-in carers for their ageing relatives. In Italy, migrant live-in carers 
are estimated to account for about three-quarters of all home-carers26. Such practices are also 
increasingly  common  in  some  central  European  countries  (e.g.  AT  and  DE27),  though  on  a 
smaller scale. 

Migrants  also  make  up  an  increasing  proportion  of  formal-care  workers  in  Member  States 
with  extensive  services,  especially  where  staff  shortages  have  encouraged  them  to  develop 
policies to attract migrants in a controlled way. Big differences in pay and working conditions 
among Member States influence the inflow of mainly female migrant workers. 

3.4. 

Typology of LTC provision in the EU27 

Recent comparative research under the 7th Framework Programme suggests that rather than 
viewing EU27 variance in LTC provision as a continuum from large to small it makes more 
sense to view it as clustered into a number of variations that can be organised into a typology 
of  delivery  models.  Building  on  a  clustering  developed  by  the  ANCIEN  project28  for  21 
countries, an overview of the key differences between the 27 Member States can be obtained 
by organising them into a typology of five modes of long-term care delivery. 

26  

27  

28  

Lamura,  G.  et  al.,  (2008),  ‘Les  travailleurs  immigrées  dans  le  secteur  de  l’aide  aux  personnes  âgées: 
l’example de l’Italie’. 
Jandl, M., Hollomey, C. and Stepien, A. (2007), Migration and Irregular Work in Austria — Results of 
a  Delphi-Study,  International  Migration  Papers  90,  International  Centre  for  Migration  Policy 
Development, Geneva: ILO. 
Kraus M. et al (2010), ANCIEN, A Typology of Long-Term Care Systems in Europe. In the map on the 
following page the Member States listed between brackets were not fully covered in the study. 

EN 

12 

   EN 

                                                 
3.5. 

Typology of LTC systems in the EU27: Spatial map and legend 

Nature of the system 

Countries 

Characteristics 

Cluster A 
Formal-care (FC) oriented 
provision, generous, accessible 
and affordable  

Denmark, 
The Netherlands, 
Sweden  

Cluster B 
FC of medium accessibility 
Some informal care (IC) 
orientation in provision  

Cluster C 
FC of medium to low 
accessibility 
Medium IC orientation in LTC 
approach 
Cluster D 
Low FC accessibility 
Strong IC orientation in LTC 
approach 
Cluster E 
Rather low FC accessibility 
Almost exclusive IC 
orientation in LTC approach 

Belgium,  
Czech Republic,  
Germany,  
Slovakia, 
(Luxembourg) 
Austria, 
England, 
Finland, 
France, 
Spain, (Irland) 
Hungary, 
Italy, 
(Greece), (Poland),  
(Portugal), (Slovenia) 
(Bulgaria), (Cyprus) 
(Estonia), (Lithuania), 
(Latvia), (Malta), 
(Romania) 

Public provision of LTC financed from general 
revenue allocations to local authorities 
High public and low private spending on FC 
Low Informal Care (IC) use, high IC support 
Modest cash-for-care benefits 
Obligatory social insurance against LTC risk 
financed from contributions 
Medium public and low private FC spending 
High IC use, high IC support, 
Modest cash-for-care benefits 
Social insurance against LTC risk financed 
from contributions or general revenue 
Medium public and private FC financing 
High IC use, high IC support 
High cash-for-care benefits  
Modest social insurance against LTC risks 
Low public and high private FC financing, 
High IC use, low IC support, 
Low cash-for-care benefits 
Little social insurance against LTC risks 
Very low public spending on FC 
Very high IC use, little to no IC support 
No or very low cash-for-care benefits 

EN 

13 

   EN 

 
 
 
 
 
 
 
Thus,  the  taxonomy  on  the  page  above  suggests  clustering  based  on  a  combination  of 
variables  such  as:  the  relative  importance  of  formal  and  informal  care;  the  accessibility, 
generosity  and  quality  of  formal  care;  the  relative  role  of  public,  non-profit  and  for-profit 
formal care providers; the financing of formal care; the size of cash-for-care benefits; support 
for  informal  carers;  reliance  on  live-in  undeclared  carers;  the  emphasis  on  traditional 
institutional care in older peoples’ homes; etc. 

4. 

RELATIVE STRENGTHS AND LIMITATIONS OF DIFFERENT DELIVERY MODELS 

In a stylised appraisal of the relative strengths and limitations of present approaches to social 
protection29 against the risks of developing a need for long-term care in old age, a number of 
points  stand  out.  The  following  review  of  the  range  of  current  policy  mixes  focuses  on  the 
ways in which informal and formal care are financed, organised and combined30. 

4.1. 

Leaving it to families to provide informal care for their ageing kin 

Traditionally,  societies  have  relied  on  the  moral  commitment  and  willingness  of  families  to 
provide  support  for  their  older  relatives,  if  they  develop  functional  and  mental  limitations. 
This  is  the  main  approach  only  in  a  minority  of  Member  States.  But  in  all  Member  States, 
informal care plays a substantial role in care provision for older people. 

Key advantages of this approach include the seemingly low costs to public budgets; and care 
is likely to be provided by closely related and (generally) trustworthy carers, so is likely to be 
well-intended.  Moreover,  the  public  sector  does  not  have  to  organise  the  financing, 
monitoring or delivery of such care. 

Drawbacks: the near absence of direct public expenditure does not mean that family care is 
free.  It  comes  at  significant  cost  to  families  (i.e.  primarily  women  as  spouses,  daughters  or 
daughters-in-law) in terms of the working time of the carer, alternative employment income 
foregone  and  reduced  accrual  of  social  protection  entitlements.  There  may  also  be  out-of-
pocket payments for care tools and assistive devices. 

The principle that every family is expected to care for its own family members also implies 
that there is no sharing of the burden/cost of care across families. In this approach, there is no 
pooling  of  the  long-term  care  risk.  Those  with  relatives  in  need  of  care  do  not  receive  any 
public support. Those with ageing relatives that can manage without LTC do not share in the 
societal LTC burden. 

The rights of older people in need of LTC will therefore depend on the ability and willingness 
of  their  families  to  provide  them  with  care.  There  are  few,  if  any,  means  to  influence  the 
quality and appropriateness of care that untrained informal carers provide. Neither the quality 
nor the sufficiency of informal care can be guaranteed. Neglect and even abuse may occur for 
lack of family resources to provide care, or as an unintended consequence when family carers 
are exposed to the physical and mental stress of being alone with care duties and to the social 
hardship this may involve. 

For  society,  family  care  involves  opportunity  costs  as  carers  reduce  their  labour  force 
participation and contribute less to GDP. In addition, the physical and mental stress and social 
hardship  that  informal  care-giving  can  induce  may  hamper  the  future  health  status  and 

29  

30  

The stylised approach simplifies actual policy mixes to bring out essential differences. For an overview 
of country-linked policy-mix typologies other than ANCIEN see Colombo et al.: Help Wanted, OECD 
2011. 
Outcomes of different policy mixes are also affected by cultural (societal and individual) differences. 

EN 

14 

   EN 

                                                 
material  well-being  of  the  care-givers  themselves.  The  rather  limited  possibilities  for 
improving productivity means that informal care delivery remains highly labour-intensive. 

In  short,  when  fully  analysed,  this  approach  has  serious  deficiencies  in  terms  of  equity, 
opportunity costs and efficiency. 

4.2. 

Getting  families  and  households  to  pay  out  of  pocket  for  their  informal  care 
needs 

A  variation  on  this  model  involves  the  family  hiring  someone  from  outside  the  family  to 
provide informal care, possibly even taking on the role of live-in carer. 

Key advantages: There is no public involvement in financing and organising long-term care. 
This can be seen as a solution to care needs if families are unable to provide care themselves, 
or if formal services are unavailable or unaffordable. Family members need not miss out on 
employment opportunities. On the contrary, they are likely to have paid employment to pay 
for the live-in carers. 

However, as this approach tends to involve undeclared work — and by illegal immigrants — 
there are indirect costs in taxes foregone. While the hired carers may prefer this work to the 
alternatives open to them, their services are affordable because they are clearly underpaid and 
do  not  earn  entitlements  to  social  protection.  In  some  Member  States  where  live-in  migrant 
carers deliver a substantial part of LTC provision policy makers have sought to mitigate these 
problems by legalising and formalising such arrangements. As above, the downsides are that 
the quality of care cannot be guaranteed, and prospects of better productivity and quality are 
very limited. 

4.3. 

Providing support to family carers 

Another  option  is  for  the  authorities  to  organise  support  for  informal  care.  This  may  entail 
economic  support,  through  a  contract  involving  a  cash  allowance  for  care  performed,  or 
crediting  of  social  protection  entitlement,  as  well  as  training  and  care  leave.  It  can  also 
involve offering protection in legislation or collective agreements to help reconcile informal 
care duties with formal employment for family carers31. 

Key  advantages  are  that  the  willingness  and  ability  of  family  members  to  provide  informal 
care  is  harnessed  at  relatively  limited  costs  to  public  budgets,  while  some  social  protection 
pooling of the LTC risk is secured. There is some quality assurance and some monitoring that 
needs are in fact met. Training and care leave takes significant pressure off carers, which may 
have  positive  effects  on  the  quality  of  care  provided  by  the  family.  The  likelihood  of  the 
primary carer leaving her employment may be reduced, especially if some formal respite care 
is available when necessary32. 

The drawbacks are less of a concern than in the other variants relying on informal care. But 
the  cost  to  families  can  still  be  considerable  and  there  is  only  limited  risk  pooling  for  LTC 
needs. Unless support covers home adaptations and support for assistive devices, productivity 
improvements are still likely to be limited. 

31 
32  

Dublin Foundation study. 
Family  carers  may  acquire  knowledge,  skills  and  competences  through  their  caring  activities,  which 
employers and unemployment services could take into account if they are recognised, even though they 
have been acquired in an informal way. 

EN 

15 

   EN 

                                                 
4.4. 

Replacing  informal  with  formal  care  in  various  models  of  LTC  financing  & 
delivery 

4.4.1.  Publicly financed public provision 

The greatest involvement of the public sector is found in those Member States where LTC is 
financed  from  general  tax  revenue,  organised  as  a  public  service  and  delivered  by  trained 
public sector workers to those  who need care. This is then an individual right (e.g. DK and 
SE). In those countries, most LTC services take the form of home help and home care, while 
nursing care is reserved for people suffering from severe mental and physical limitations. 

Key  advantages  include:  a  solid  financing  base  with  full  pooling  of  LTC  risks  across  the 
population;  maintenance  of  a  larger  formal  workforce  contributing  to  GDP;  jobs  with 
upgrading  opportunities  for  lower-skilled  workers;  well-trained  professional  carers;  and 
alleviation  of  the  burden  on  families,  so  that  people  with  dependent  elderly  relatives  can 
continue  full-time  employment.  The  rights  of  those  needing  care  are  far  better  protected. 
Quality  can  be  fully  monitored  and  there  are  opportunities  for  growth  in  productivity, 
including through re-engineering and capital substitution33. Taking care into the formal sector 
unlocks it from the constraints of families and makes the cost of delivering long-term care far 
more visible and amenable to public policies. 

Drawbacks are that it tends to involve far higher public spending on long-term care (though 
not necessarily much higher societal cost) and that public authorities assume the bulk of the 
responsibility  of  social  protection  against  long-term  care  risks  in  old  age.  Confronted  with 
constrained  choices  between  various  spending  items  addressing  the  different  needs  of 
different  categories  of  citizens,  policy  makers  face  the  difficult  task  of  securing  affordable 
quality  care  while  offering  decent  pay  and  working  conditions  to  publicly  employed 
professional carers. Obviously, the supply and quality of care (and protection against the risks 
of becoming dependent) may fall short of needs and expectations. Public budget constraints 
can  have  an  immediate  negative  impact  on  the  amount  and  quality  of  care  provided. 
Moreover, the lack of a direct link between the financing of care and entitlements can weaken 
the  sustainability  of  systems  and  the  ability  of  older  people  who  need  long-term  care  to 
enforce their rights to definite amounts of care of appropriate quality. 

4.4.2. 

Social-insurance funded care, delivered by private non-profit or for-profit providers 

In this variant, non-profit NGOs such as welfare associations and faith-affiliated social service 
organisations deliver the bulk of formal care. For-profit providers may also have a role, but in 
most Member States, this is rather limited and primarily concerns residential or nursing home 
care.  Services  may  be  paid  directly  by  a  social  insurance  body  or  may  be  payable  with 
vouchers or care allowances provided to care recipients. 

Advantages:  Generally,  this  approach  can  lessen  the  burden  on  families,  as  is  the  case  in 
countries with public provision, though in some Member States, it coexists with an emphasis 
on  informal  care,  for  which  it  may  also  provide  some  financing.  Where  social  insurance  is 
mandatory,  it  provides  broad  risk-pooling  and  a  rather  solid  financing  base.  Expenditure  is 
covered by earmarked social security taxes and is therefore less open-ended than in systems 
with  financing  from  general  revenue.  Entitlements  tend  to  be  easier  to  enforce  as  they  are 
backed by contributions and may entail clear definitions of the amount and type of care to be 
provided to people with certain diagnoses of dependency. An environment with more types of 
care providers can allow more consumer choice and may result in competition, with a positive 

33  

Re-engineering  involves  changing  the  way  social  protection  against  the  LTC  risk  is  organised,  e.g. 
through  a  greater  emphasis  on  prevention  and  empowering  for  self-sufficiency.  Capital  substitution 
entails replacing and amplifying human labour by productivity-enhancing technology. 

EN 

16 

   EN 

                                                 
impact  on  quality  and  cost.  It  may  also  make  long-term  care  a  more  attractive  field  of 
employment, as professional carers can build careers with various types of employers. 

Drawbacks: Contributions are levied on a somewhat narrower tax base than general revenue 
and will have to be raised as needs increase. Reimbursements, care allowances and vouchers 
may  not  cover  the  total  price  of  care,  thus  requiring  some  out-of-pocket  payments  by 
recipients  or  their  families.  The  separation  between  financing  and  care-providing  bodies 
makes quality control more complicated, but may generate incentives to productivity drives. 
Preventive measures, such as home adaptations and access to day-care facilities may not be 
(fully) covered. Access to rehabilitation may not be covered or fully reimbursed. 

4.5. 

In sum 

Current approaches to social protection against long-term care risks differ widely in terms of 
risk pooling and equity in access. Policies also differ markedly in their capacity to optimise 
the quality and efficiency of care delivery. Approaches with a heavy emphasis on family care 
are at a particular disadvantage in relation to these key dimensions of care provision. Given 
future challenges these disadvantages are set to become major deficiencies. 

In many Member States, public expenditure is at present only the tip of the iceberg when it 
comes  to  calculating  the  societal  cost  of  caring  for  frail  older  people  in  Europe.  Expanding 
formal  services,  leading  to  higher  public  expenditure,  will  result  in  hitherto  hidden  costs 
becoming visible, with social protection to cover long-term care being developed to share the 
risks  of  disability  in  old  age  more  equitably.  Importantly,  it  will  not  be  possible  to  ensure 
equality of access to long-term care, guarantee its quality or develop productivity unless most 
of the current informal care is lifted into the formal sector. 

5. 

5.1. 

POLICY OPTIONS FOR ADDRESSING FUTURE LTC CHALLENGES 

The overall challenge in LTC 

Over the next five decades, the shrinking of the population of working age will tend to limit 
economic  growth  and  make  it  more  difficult  to recruit  formal  carers.  Changes  in  living  and 
family  arrangements,  a  rise  in  female  labour  force  participation  rates  and  higher  retirement 
ages will reduce the reservoir of informal carers. At the same time, the threefold increase in 
the number of those in the age groups most likely to need long-term care is likely to lead to 
very  substantial  growth  in  demand  for  such  care.  In  short,  the  challenge  is  to  find  ways  to 
contain  the  growth  in  demand  for  long-term  care  while  improving  the  capacity  to  provide 
more, better care with fewer human resources and less funding. 

5.2. 

The challenge for public budgets 

The  Ageing  Report  2012,  which  examines  the  challenge  in  terms  of  its  impact  on  public 
spending,  expects  that  the  steep  rise  in  the  number  of  people  aged  80+  will  generate  a 
substantial  increase  in  needs  for  long-term  care,  raising  pressure  to  expand  care  provision. 
The effect of  ageing  itself  is  expected  to  result in at least a doubling of public spending on 
LTC for the EU27, i.e. from 1.8 % to 3.6 % of GDP in the period 2010-2060 (as shown by the 
so-called ‘base case scenario’). 

It is therefore important to find ways to limit the growth in public spending, while avoiding a 
rapidly widening gap between the need for care and the supply available. 

EN 

17 

   EN 

 
5.3. 

Policy responses needed to tackle the challenges 

National policy makers are seeing the future challenge for long-term care as that of ‘closing 
the gap’ between growing care needs and stagnant to shrinking resources. The key questions 
are  finding  policy  mixes  that  can  enable  Member  States  to  close  that  gap.  Important 
contributions towards doing so could conceivably come from: 

• 
• 
• 

raising the productivity of care delivery 
reducing the incidence and overall prevalence of frailty and disability 
reducing  dependency,  i.e.  enabling  older  people  to  continue  to  manage  independent 
living with functional limitations 

The  first  element  in  a  coherent  strategy  concentrates  on  possibilities  for  delivering  more, 
better  care  with  fewer  resources  in  terms  of  manpower  and  money.  The  others  focus  on 
containing the growth in needs for long-term care, through measures to prevent morbidities or 
to slow their disabling course, while enabling elderly people to manage without care, or with 
far less care than today, despite functional limitations. 

The  productivity  of  care  provision  can  be  raised  through  better  organisation,  financial 
incentives, quality control and re-engineering including through capital substitution. Current 
change and innovations suggest that productivity growth will be far greater than assumed in 
standard labour economics. Systematic productivity drives will be limited to formal long-term 
care  and  it  will  therefore  be  important  to  replace  informal  by  formal  care.  But  support  for 
family  carers,  through  ICT  and  assistive  devices,  for  instance,  can  also  help  raise  both  the 
productivity and quality of informal care. 

Active and healthy ageing and a determined emphasis on prevention and rehabilitation can 
reduce the incidence of frailty, postpone its onset and reverse or mitigate the course of frailty, 
functional  limitations  and  disability.  People  who  are  fit  when  they  become  old  and  seek  to 
remain physically and mentally active not only have a better chance of avoiding or postponing 
frailties, they are often also better at managing functional decline when it occurs. 

General  prevention  and  health  promotion  schemes  for  all  ages,  with  special  awareness 
programmes for people in their 50s to very old people hampered by functional limitations, can 
be built into social protection. Avoiding premature erosion of physical and mental fitness and 
damage  inflicted  through  mal-medication  and  accidents  such  as  falls  would  bring  large 
benefits, both in cost savings and quality of life. It will be important for prevention policies to 
target some of the main diseases/physical conditions that cause dependency. Another priority 
would  be  to  promote  early  detection  of  emerging  limitations  and  frailties,  and  to  offer 
mitigating  measures,  including  assistive  aids.  A  wide  range  of  preventive  measures  and 
policies  have  been  demonstrated  to  be  clinically  effective.  Encouraging  senior  citizens  to 
participate  in  physically  and  mentally  stimulating  activities  in  various  settings,  such  as 
universities, language schools, sport centres, volunteering organisations and day care centres, 
can halt the course of decline and help maintain and sharpen faculties34. 

A  fall  leading  to  a  broken  hip  or  a  spell  of  serious  illness  can  send  an  otherwise  fit  older 
person  into  rapid  decline,  requiring  extensive  care.  But  cost-effective  rehabilitation  has 
proved to be possible even in late stages of life. Obviously, rehabilitation is most effective if 
provided immediately after an incident, before serious frailties set in. Several Member States 
have  included  rehabilitation  in  their  long-term  care  approaches  as  a  cost-effective  tool, 
although this is not yet standard practice. 

34  

Susann  Rohwedder  and  Robert  J.  Willis,  Mental  Retirement,  Journal  of  Economic  Perspectives—
Volume 24, Number 1—Winter 2010, pp. 119–138. 

EN 

18 

   EN 

                                                 
Physical and mental restrictions in older people need not be perceived as ill health and a threat 
to  their  ability  to  lead  independent  lives  as  long  as  sufficient  resources  are  available  to 
compensate for the deficits. It will be crucial to make the necessary social investments in age-
friendly adaptations of older people’s private homes and in new assistive devices, including 
those  that  allow  for  self-monitoring,  self-care  and  self-management.  This  is  about 
empowering and enabling older people with functional limitations to manage a higher degree 
of self-sufficiency. ICT can facilitate social interaction with family and friends and allow for 
emotional  support,  even  when  people  are  largely  bound  to  their  homes  and  relatives  do  not 
live nearby. Public procurement can be used to secure assistive devices at affordable prices. 
Public  policies  can  also  encourage  older  people  and  their  relatives  to  pay  out-of-pocket  for 
assistive devices to help older people look after themselves day-to-day. The aim would be to 
enable and empower older people with functional limitations to get by with much less long-
term  care  than  today,  so  that  they  can  retain  autonomy  with  choice  and  dignity  despite  the 
physical and mental effects of ageing. 

Well-known concepts such as ‘ageing in place’, ‘continuity in care’, ‘care integration’ ‘self-
care’  and  ‘smart  homes’  would  be  part  of  strategies  that  can  successfully  begin  to  tackle 
future  challenges  in  long-term  care.  Social  experimentation  followed  by  dissemination  and 
scaling up of successful approaches have for some time formed part of long-term care strategy 
development  in  Member  States  such  as  DK,  NL,  SE  and  the  UK.  Ageing  in  place, 
independent  living  and  rehabilitation  can  be  achieved  through  age-friendly  environments, 
assistive technology and appropriate provision of home help and home care. 

For  some  countries  with  well-developed  formal  provision,  focusing  on  prevention, 
productivity  and  independent  living  will  seem  a  logical  extension  of  present  efforts.  Others 
will  have  to  make  substantial  changes.  If  risks  are  to  be  effectively  shared  and  individual 
needs guaranteed, genuine social protection programmes covering long-term care will have to 
be developed. This will involve shifting care from the informal to the formal sector to develop 
the productivity and quality of care delivery systematically. It will entail making visible the 
hitherto  hidden  privatised  cost  of  long-term  care.  But  it  will  also  offer  the  prospect  of 
substantial GDP growth and higher employment rates. This way, Member States can benefit 
in major ways from formalising and modernising their LTC provision. 

Key questions for further investigation would be: 

•  To  what  extent  can  prevention  and  rehabilitation  affect  the  incidence  and  course  of 

frailty and disability in old age? 

•  To what extent can systematic productivity drives in care delivery, including thorough 
capital substitution and service innovation, bring possibilities for delivering more and 
better care with less manpower? 

•  How  much  potential  is  there  for  raising  the capacity  of frail older people to  manage 
independent living through age-friendly adaptations, smart technologies and assistive 
devices? 

•  Would a combination of these complementary approaches, which require determined 
social investments over a long period, be sufficient to bridge the gap between the need 
for long-term care and the supply? 

Obviously, these questions cannot be fully answered in this paper. But a review of some 
good  practices  in  Member  States  can  give  an  insight  into  the  potential  of  a  social 
investment approach to the long-term care challenge. 

EN 

19 

   EN 

6. 

GOOD  PRACTICES 
APPROACHES TO LTC 

IN  MEMBER  STATES  APPLYING  SOCIAL 

INVESTMENT 

Key elements of the necessary strategy are already emerging in several Member States. This 
chapter  summarises  some  good  practices35  in  preventive  approaches  to  healthy  and  active 
ageing,  successful  rehabilitation,  efforts  to  improve  the  capacity  for  independent  living, 
support for informal carers and the  use of ICT in drives for  higher productivity. Practices 
reviewed also include measures to create more age-friendly environments, including support 
for home adaptations, and efforts to raise quality in both formal and informal care provision. 

6.1. 

Comprehensive national approaches 

In Sweden, policies have begun to combine the complementary strategies of (1) productivity 
drives,  (2)  health-promoting  and  preventive  measures  and  (3)  investments  in  home 
adaptations, ICT and assistive devices to enable older people to continue living independently 
even  after  developing  functional  limitations.  National  policies  are  increasingly  oriented 
towards  using  combinations  of  efforts  in  these  three  areas  to  bridge  the  gap  between  care 
needs  and  provision,  which  would  otherwise  grow  larger  over  the  next  30  years.  It  is 
estimated  that  systematic  efforts  of  this  sort  over  a  long  period  can  enable  Swedish 
municipalities to continue to meet demand for long-term care. 

In  Denmark,  where  long-term  care  is  provided  by  local  government,  the  municipality  of 
Fredericia36 realised that the age profile of its population in 15 years’ time would make it very 
difficult to meet long-term care needs through existing approaches. It decided to embark on a 
new  strategy  to  encourage  and  enable  elderly  people  to  live  independently  for  as  long  as 
possible. Experiences with a so-called ‘rehabilitation for everyday life’ approach demonstrate 
that with teams of physiotherapists and ergonomists, it is possible to bring many older people 
from  needing  care  on  a  regular  basis  to  basic  self-sufficiency  and  autonomy.  Through 
combining  preventive  measures  of  active  and  healthy  ageing,  greater  productivity  in  care 
delivery can be achieved. While raising the ability of frail elderly to manage independently, 
Fredericia has documented the possibility of raising the overall quality of protection against 
LTC risks. In addition, job satisfaction for formal care staff can be improved at lower costs, 
with  fewer  staff.  Some  of  these  innovative  approaches  are  becoming  part  of  overall  policy 
approaches in areas of the UK and Germany. 

6.2. 

Prevention 

A preventive approach is preferable to acute and reactive care, not only in financial terms but 
also regarding the individual’s health status. Encouraging older people to remain independent 
in their home and community, while staying socially active, can bring significant savings in 
the short, medium and longer term. Prevention should be regarded as an investment, as also 
exemplified by the ‘Re-ablement’ approach discussed in the Annex. Integrated care based on 
collaboration  within  health  care  services  and  among  social,  health  and  community  care 
providers results in better outcomes for older people, while addressing resource efficiency and 
sustainability. This is illustrated by the LinkAge Plus programme cited in the Annex. 

Health promotion and prevention also involve quality assurance in different aspects of care. 
Studies have shown that 17 % of older people use at least one inappropriate medication and 
that  almost  60 %  of  older  out-patients  take  medications  that  are  suboptimal  or  lacking  an 
indication37. Adverse drug reactions or events (ADRs or ADEs) include falls with or without 

35  
36  
37  

Please consult the Annex for further details. 
See: http://www.fredericia.dk/Borger/Sider/default.aspx. 
http://www.dh.gov.uk/health/2012/03/new-medicines-service/. 

EN 

20 

   EN 

                                                 
fractures  and  more  general  geriatric  syndromes  (e.g.  cognitive  impairment,  urinary 
incontinence, etc.). 

6.3. 

Rehabilitation 

Although not yet common practice, rehabilitation at an early stage, properly used, has proved 
to  be  cost-effective  in  long-term  care  and  highly  beneficial  for  patients.  Research38  has 
identified  general  success  factors  for  rehabilitation  programmes.  In-patient  geriatric  care 
should be combined with out-patient geriatric follow-up, based on early recognition of patient 
needs.  Frailer  participants  generally  benefit  from  individualised  interventions,  while  group 
interventions  are  successful  for  the  less  severely  disabled39.  An  effective  rehabilitation 
programme  must  start  with  a  multidimensional  geriatric  assessment  in  which  problems  are 
identified  and 
that 
recommendations are properly implemented. 

recommendations  are  drawn  up.  Monitoring  should  ensure 

Successful  innovative  practices  have  been  developed  for  strokes,  traumatic  brain  injury  and 
hip fractures. In most cases, respiratory rehabilitation and cognitive rehabilitation can now be 
implemented. In some Member States, rehabilitation is clearly identified as a specific service 
(e.g.  Germany,  see  the  Annex),  whereas  in  others  (e.g.  England,  Denmark,  Sweden  and  the 
Netherlands) it is an integrated part of comprehensive programmes of health care and health 
promotion. 

6.4. 

Productivity and capacity gains from innovation, including through use of ICT 

The use of ICT (information and communication technologies) to support carers and increase 
the  productivity  of  care  delivery  is  spreading  in  Member  States  and  gradually  moving  from 
the  experimental  stage  to  being  scaled-up,  thus  innovating  and  improving  the  way  care  is 
organised and delivered and the way home environments are adapted40 41. 

Social and ICT innovations enable new ways of organising society around active ageing and 
independent living for older people, as shown by the CARICT project for all of Europe (see 
Annex)  and  by  examples  from  Scotland,  England  and  Italy.  These  new  approaches  have  all 
brought  higher  productivity  and  substantial  savings  while  raising  the  quality  of  services  as 
well as the quality of life of older people with LTC needs and their carers. 

6.5. 

Quality assurance 

Quality assurance in LTC remains a major challenge in a context of workforce shortages, the 
complexity of delivery and the difficulty of monitoring. However, some Member States have 
already  made  major  efforts  to  improve  quality,  combating  elder  abuse  and  promoting  the 
professionalisation of long-term care delivery. In the field of prevention of elderly abuse, the 
Dutch  policy  (see  Annex)  stands  out  as  particularly  innovative  and  thorough.  The 
implementation  of  the  recent  Borloo  Plan  in  France,  which  covers  various  aspects  of  the 
organisation  and  delivery  of  LTC,  stands  out  as  a  key  initiative  to  tackle  a  multitude  of 
weaknesses in provision by launching a comprehensive national approach. 

38  
39  
40 
41  

Reference to be added. 
Reference to be added. 
See: http://is.jrc.ec.europa.eu/pages/EAP/eInclusion/carers.html. 
JRC (2013) Can technology -based services support long-term care challenges in home care? Analysis 
of Evidence from Social Innovation Good Practices across the EU: CARICT Project Summary Report. 
Authors: Carretero, S.; Stewart, J.; Centeno, C.; Barbabella, F.; Schmidt, A.; Lamontagne-Godwin, F. 
and Lamura, G. JRC Scientific and Technical Reports Series, EUR 25 695 EN, at: 
http://ipts.jrc.ec.europa.eu/publications/pub.cfm?id=5899. 

EN 

21 

   EN 

 
                                                 
 
This brief review of innovative approaches to providing long-term care emerging in Member 
States  illustrates  the  potential  returns  from  pursuing  innovation-driven  social  investment 
strategies and their potential in efforts to avert a crisis in unmet needs as the number of old 
people grows. 

7. 

CONTRIBUTIONS FROM EUROPE

42 

The  EU  can  offer  Member  States  significant  support  in  their  efforts  to  tackle  present  and 
future challenges in LTC. The diversity of systems is a major opportunity for mutual learning, 
for which the EU can act as a facilitator. A number of policy departments are already involved 
in these matters and involved in facilitating the exchange of experience among Member States 
and stakeholders. 

7.1. 

Prevention 

Healthy ageing and independent living have been promoted in Member States as part of the 
European  Year  2012  for  Active  Ageing  and  Solidarity  between  Generations.  Upon  joint 
suggestion  from  the  Social  Protection  Committee  (SPC)  and  the  Employment  Committee 
(EMCO)  the  Council  on  6  December  2012  adopted  Guiding  Principles  for  Active  Ageing, 
which  highlight  the  following  policies  as  key  routes  to  autonomy  and  independent  living  in 
old age: Health promotion and disease prevention; Adapted housing and services; Accessible 
and  affordable  transport;  Age-friendly  environments  and  goods  and  services;  Maximising 
autonomy in long-term care. 

The Active Ageing Index (AAI)43 is a new monitoring tool developed by the European Centre 
Vienna in collaboration with the United Nations Economic Committee for Europe (UNECE) 
and  the  European  Commission’s  DG  Employment,  Social  Affairs  and  Inclusion.  The  index 
measures the performance of countries in four domains that together determine active ageing 
potential:  (1)  employment  of  older  workers;  (2)  social  activity  and  participation  of  older 
people; (3) independent and autonomous living of older persons; and (4) an environment that 
enables active ageing. The index aims to help shape future research and policy agendas and 
influence how existing large-scale data-sets are developed to address the impact of population 
ageing by following the policy discourse on active ageing and solidarity between generations. 

Taken  together,  these  policies,  already  developing  in  Member  States,  to  some  extent  with 
comprehensive  commitments  to  social  protection  against  LTC  risks  in  old  age,  are  a 
promising  social  investment  approach  to  containing  the  growth  in  LTC  needs  while  raising 
the  ability  of  older  people  to  live  independently.  Importantly,  EU  policies  can  underpin  the 
further roll-out of such policy efforts at national level. There has been collaboration on LTC 
issues at EU level over the last decade, notably in the Economic Policy Committee (EPC) and 
the Social Protection Committee (SPC). 

42  

43  

This is only a brief summary. A fuller inventory of European initiatives of relevance is given in here: 
www.ec.europa.eu/social/BlobServlet?docId=8710&langId=en. 
See: 
http://europa.eu/ey2012/ey2012 main.jsp?catId=975&langId=en&mode=initDetail&initiativeId=186&i
nitLangId=en. 

EN 

22 

   EN 

 
                                                 
 
Productivity and capacity gains from innovation including through use of ICT 

7.2. 
ALIAS  (AAL  Joint  Programme44)  has  developed  a  mobile  robot  system  that  interacts  with 
elderly users and provides assistance in daily life, promoting healthy ageing and independent 
living. 

Public  procurement  policies  and  new  European  instruments  for  long-term  investment  can 
help  establish  the  environment  for  large-scale  European  production  of  innovative  assistive 
devices at affordable prices. 

DG  CNECT  has  for  decades  followed  technology  developments  that  can  help  tackle  LTC 
challenges and promote independent living. DG CNECT is involved in work on moving from 
innovation to production and marketing, and scaling up and implementation in public policy. 
Together with DG SANCO, it leads the EIP pilot on healthy and active ageing. DG CNECT 
also co-funds projects such as the CARICT Project45 at the EC JRC46. This project documents 
the  role  played  by  ICTs  in  supporting  informal  carers.  InCasa  (ICT-PSP)  has  developed  an 
ICT-based system to protect frail elderly persons and prolong the time they can live well in 
their own homes. 

7.3. 

The European Innovation Partnership Pilot on Active and Healthy Ageing (EIP 
AHA) 

This initiative aims to identify and remove barriers to innovation in health and long-term care 
delivery.  By  intensifying  work  between  all  stakeholders  on  innovative  solutions,  it  seeks  to 
increase  our  ability  to  scale  up  good  practices  and  secure  faster,  large-scale  deployment  of 
new knowledge and technology. The overarching objective is to extend average healthy life 
years in the EU by 2 years by 2020. The partnership brings together various stakeholders from 
the  demand  and  supply  side  and  promotes  the  development  of  innovative  products  that 
contribute  to  healthy  ageing  and  facilitate  the  independent  living  of  frail  older  people.  The 
focus  is  on  three  areas:  (1)  prevention  and  health  promotion,  (2)  health  and  social  care  for 
older  people  and  (3)  active  ageing  and  independent  living  of  older  people  supported  by 
innovative products. 

The  ICT  research  programme  has  for  decades  supported  technology  developments  to  help 
tackle LTC challenges and promote independent living. The Competitiveness and Innovation 
Programme  supports  moving  from  innovation  to  production  and  marketing,  and  scaling  up 
and implementation in public policy. 

The Lifelong Learning Programme and its successor will help facilitate independent living by 
providing funding for the acquisition of ICT skills by seniors. 

7.4. 

Quality assurance 

In the SPC, Member States have compared approaches and exchanged experiences in relation 
to  common  objectives  of  guaranteeing  access  for  all  to  adequate  long-term  care,  while 
promoting quality and ensuring that adequate, high-quality long-term care remains affordable 

44  

45  
46  

The  Ambient  Assisted  Living  Joint  Programme  is  a  joint  research  and  development  funding 
programme. Its main objectives are to improve the living conditions of older people through the use and 
development  of  AAL  solutions  based  on  ICT  technologies,  and  to  strengthen  the  competitiveness  of 
European industry in the AAL domain. For further information see: http://www.aalforum.eu/page/aal-
joint-programme. 
See: http://is.jrc.ec.europa.eu/pages/EAP/eInclusion/carers.html. 
See: http://is.jrc.ec.europa.eu/pages/EAP/eInclusion/carers.html. 

EN 

23 

   EN 

 
 
                                                 
and sustainable. In the Joint Reports on Social Protection and Social Inclusion, Member States 
have  reported  on  their  approaches  and  recent  progress  towards  the  common  objectives. 
Various peer-reviews on LTC in the Member States have provided opportunities for mutual 
learning. Member States have also sought to agree a set of common indicators for measuring 
advances towards the common objectives, and in 2008, the SPC adopted a special report on 
LTC. The SPC has also agreed a European Quality Framework for social services of general 
interest,  including  LTC  services.  Still,  LTC  has  remained  the  least-developed  of  the  social 
protection  strands  for  which  Member  States  have  agreed  common  objectives.  Recognising 
this, the SPC has recently stepped up its work on LTC issues in its subgroup on ageing issues 
in social protection SPC-WG-AGE. This group is currently considering a proposal for a major 
work programme on Innovative Approaches to LTC, which may run till the end of 2013. 

Beyond  the  work  of  these  committees,  LTC  issues  have  been  covered  in  the  Research 
Programmes of the EU and in work on the potential of ICT developments to care for older 
people and ensure independent living. The Ambient Assisted Living Joint Programme (AAL) 
aims to enhance the quality of life for older people. It funds projects using intelligent products 
and  the  provision  of  remote  services,  including  care  services,  to  improve  the  lives  of  older 
people  at  home,  in  the  workplace  and  in  society  in  general.  It  has  a  total  budget  of  around 
EUR 700 million for the period 2008–13, sourced approximately 50–50 from public (national 
and EU) and private bodies. 

As  part  of  its  servicing  of  the  SPC  and  the  Social  OMC,  DG  EMPL  has  accumulated 
extensive experience on LTC. The unequal distribution of LTC needs has been connected to 
health  inequalities  and  arduous  working  conditions.  Long-term  care  has  been  considered  in 
opportunities for job growth and the future supply of jobs for the low-skilled (see the April 
2012 Employment Package47). In future, the structural funds, including the ESF, are expected 
to give more attention to health and social inclusion issues, entailing wider possibilities to use 
the  funds.  New  orientations  in  social  policy  towards  social  experimentation  also  offer 
prospects for innovation and improvement in long-term care provision. 

DG  JUST’s  Daphne  programme  deals  with  elder  abuse.  An  act  on  accessibility  is  planned. 
The gender equality roadmap includes a proposal to develop a directive on leave for carers.  

The European Parliament has given particular attention to the LTC-related issue of Neglect 
and Abuse of Older People and allocated money to research and NGO projects on policies to 
prevent and tackle the danger of such violations of the basic rights of frail older people. The 
AGE  Platform  is  one  of  the  organisations  that  have  examined  the  issues  and  come  up  with 
proposals for a preventive approach in the WeDO project. 

The Lifelong Learning Programme and its successor will continue to provide funding for the 
acquisition  of  skills  and  competences  by  carers,  whether  formal  or  informal,  as  well  as 
funding and tools for the recognition and validation of the skills acquired. 

Important OECD work on financing and staffing issues in LTC and on quality assurance has 
been co-funded by the European Commission48. 

47  

48  

"Towards  a  job  rich  recovery",  COM(2012)  173  final,  "Exploiting  the  employment  potential  of  the 
personal and household services, SWD(2012) 95 final and "Action Plan for the EU Health Workforce", 
SWD(2012) 93 final. 
Colombo et. Al: Help Wanted, OECD 2011 and Colombo et al.: MONITORING AND IMPROVING 
QUALITY IN LONG-TERM CARE IN OECD COUNTRIES, forthcoming OECD 2013. 

EN 

24 

   EN 

 
                                                 
7.5. 

Public finances and research 

DG ECFIN, cooperating with Member States in the Ageing Working Group of the EPC, has 
focused on how age-related increases in public expenditure for long-term care may affect the 
stability  of  public  finances.  A  methodology  has  been  developed  for  collecting  a  set  of  data 
and  carrying  out  public  expenditure  projections  for  long-term  care  over  several  decades. 
Results have been reported every third year since 2006 in the Ageing Report. Furthermore, a 
working  paper  elaborating  on  the  Ageing  Report49,  focusing  specifically  on  LTC,  has  just 
been published in the Economic Papers series50. 

The  EU  and  Member  States  have  also  launched  two  specific  Joint  Programming  Initiatives 
(JPIs) aimed at facilitating active and healthy ageing. 

The More Years, Better Lives JPI addresses the challenges and opportunities of demographic 
change  by  developing  multi-disciplinary  knowledge  as  the  basis  for  future  research, 
innovation and policy making. 

The  Joint  Programming  on  Neurodegenerative  Disease  Research  (JPND)  aims  to  increase 
coordinated investment among 13 participating countries in research aimed at finding causes, 
developing cures, and identifying appropriate ways to care for those with neurodegenerative 
diseases, in particular Alzheimer’s. As such, it will improve understanding of these diseases 
and  contribute  to  ensuring  early  identification  and  treatment  thus  reducing  the  social  and 
economic impact for patients, families and health care systems. 

Five thematic priorities for future research include: the origins of neurodegenerative disease; 
disease  mechanisms  and  models;  disease  definitions  and  diagnosis;  developing  therapies, 
preventive  strategies  and  interventions;  and  healthcare  and  social  care.  A  joint  transnational 
call was launched in December 2012 to address the evaluation of current health care policies, 
strategies and interventions for neurodegenerative diseases. 

Additional funding for research on Alzheimer’s is provided through the Innovative Medicines 
Initiative  (IMI),  a  EUR  2  billion  public–private  partnership  between  the  European 
Commission  (FP7)  and 
the  European  Federation  of  Pharmaceutical  Industries  and 
Associations  (EFPIA).  PharmaCog  is  a  pan-European  partnership  of  experts  working  on 
delivering  high-quality  Alzheimer’s  medication.  The  EMIF  (European  Medical  Information 
Network) project has the goal of creating a common information framework of patient-level 
data that will link up and facilitate access to diverse medical and research data sources. One of 
the two areas addressed will be Alzheimer’s, with a view to identifying the mechanisms that 
make some people more susceptible to the disease than others. 
In  the  6th  and  7th  Framework  Programmes  for  Research  DG  Research  has  furthermore 
financed  projects  on  health  systems  and  LTC  issues  (e.g.  ANCIEN,  INTERLINKS, 
SHELTER,  COURAGE,  RightTime  PlaceCare,  REFINEMENT,  MentDis_ICF65,  etc.)51. 
Projects  centre  on  needs  mapping,  quality  measurement,  LTC  delivery,  role  of  financing 

49  

50  

51  

See for instance: European Commission (DG ECFIN) — Economic Policy Committee (AWG), 2009, 
‘The 2009 Ageing Report: Economic and budgetary projections for the EU-27 Member States (2008-
2060)’,  European  Economy  No  2/2009;  European  Commission  (DG  ECFIN)  —  Economic  Policy 
Committee (AWG), 2012, ‘The 2012 Ageing Report — Economic and budgetary projections for the 27 
EU Member States (2010-2060)’, European Economy No 2/2012. 
Lipszyc, B. et al. (2012), ‘Long-term care: need, use and expenditure in the EU-27’, Economic Papers 
469, November 2012. 
http://www.ancien-longtermcare.eu/;  http://interlinks.euro.centre.org/;  http://lnx.starcomitaliaweb.eu/; 
http://www.healthcompetence.eu/converis/publicweb/project/3075;jsessionid=5360e5766198167404d6
43735d2b?show=Person; http://www.mentdiselderly.eu/; http://www.righttimeplacecare.eu/. 

EN 

25 

   EN 

                                                 
systems in quality of care, development of best practices in long-term care organisation, and 
specific mental health issues in old age. 

With the Administrative  Committee, the European Commission is currently examining  how 
Regulation 88352 on the coordination of social security systems can be revised to ensure better 
long-term care coverage for mobile persons. As social protection for long-term care needs is 
increasing  in  importance,  the  EU  social  security  coordination  rules  have  to  take  these 
developments  into  account.  In  2012,  the  Commission  launched  an  Impact  Assessment  to 
analyse the different options for revised rules on the coordination of long-term care benefits. 
The  aim  is  to  enhance  the  effectiveness  of  the  coordination  regime,  improve  the  social 
security  protection  of  vulnerable  citizens  wishing  to  live  in  another  Member  State  and 
improve  legal  certainty  for  all  stakeholders.  The  Commission  plans  to  finalise  the  Impact 
Assessment at the end of 2013 and to launch the revision in 2014. 

7.6. 

Possible follow-up actions 

Together,  these  initiatives  and  activities  by  the  European  Commission  and  other  EU 
institutions  form  a  framework  of  potential  support  for  developing  social  protection  against 
LTC risks. There are thus substantial possibilities at European level to offer help to Member 
States in introducing innovative social investment-oriented approaches to providing long-term 
care. 

Steering role of the SPC WG-AGE 

The immediate task at EU level should be to make more connections between these initiatives 
and  activity  areas  and  raise  synergies  between  them.  Developing  the  SPC-WG-AGE  into  a 
focal point for LTC-related activities across Commission services could be a first step. With 
regular  reporting  to  Member  State  delegates  in  the  SPC-WG-AGE  from  initiatives  run  by 
different services, a functional inventory of LTC activities could emerge and the interaction 
between these improved. 

A programme of work has been proposed with contributions from experts, Member States and 
Commission services leading to an SPC report on Innovative approaches to social protection 
against  LTC  risks.  This  would  entail  involvement  of  or  contact  with  external  partners 
whenever required. 

The  intention  is  to  organise  knowledge  generation  and  best  practices  exchange  to  explore 
avenues to innovative, better social protection against LTC risks in view of the shared OMC 
goals.  Ideally,  such  social  protection  would  consist  in  a  continuum  of  policies  from  early 
prevention  to  practical  delivery  of  LTC,  including  the  role  of  informal  care.  Thematic 
meetings would include a keynote address from an expert followed by presentations from one 
or  two  Member  States  with  particular  experience  in  the  topic  under  investigation.  Each  of 
these would be used to introduce discussions and exchanges of expertise between delegates. 

Among  the  key  challenges  for  policy  makers  and  stakeholders,  this  proposal  for  a  work 
programme focuses on the following: 

-  limiting  the  growth  of  LTC  needs  through  prevention,  rehabilitation,  and  increased 
capacity for independent living 

- ensuring access to LTC services for those in need 

- securing the quality of care 

- maintaining the financial sustainability of LTC delivery 

52  

Regulation (EC) No 883/2004 of the European Parliament and of the Council of 29 April 2004 on the coordination 
of social security systems 

EN 

26 

   EN 

                                                 
In order to address these issues, a sequence of thematic working meetings is set out. At each 
step,  the  involvement  of  DG  SANCO  is  clearly  required,  and  for  each  topic  covered  the 
gender dimension should be clearly addressed. 

Expected contribution from JRC-IPTS 

A new JRC-IPTS project for 2013-14 aims to support DG EMPL in helping Member States to 
develop long-term care strategies promoting independent living of older adults — especially 
frail  adults  —  through  technology-based  solutions.  These  solutions  cover  any  kind  of 
technology,  including  ICT,  that  empowers  clients  to  manage  despite  frailties  (self-
sufficiency), better organises the provision of care or increases the productivity and quality of 
long-term care delivery (capital substitution for care manpower). 

The main objective is to produce guidelines for the Member States to design long-term care 
strategies than can increase the capacity of older adults for independent living even when they 
become frail or contract multi-morbidities, with the use of technology and based on the case 
studies of good practices. This project will have the following specific objectives: 

•  To identify good practices in technology-based services and solutions for independent 
living  at  home  for  different  needs  of  older  adults,  which  have  been  successfully 
implemented. 

•  To analyse the good practices case by case in terms of business case, business model, 
technology and organisational change, technical standards, quality, scale and scale-
up, and national and EU role for leadership and transfer. 

•  To  produce  a  manual  for  policy  makers  on  long-term  care  strategies  for  policies  to 
increase the capacity of older adults for independent living with the use of technology. 
•  To  identify  the  role  of  the  EU  in  supporting  Member  States  in  implementing  these 

technological services. 

The specific added value of this project is helping decision-makers make an informed choice 
on this important topic, also from an economic and technical point of view and with regard to 
their own LTC delivery situation. The approach is definitely pragmatic and policy-oriented. 

8. 

CONCLUSION 

Europe needs to prepare for a tripling of the number of people in the age group where people 
are  most  likely  to  need  long-term  care.  The  current  modes  of  responding  to  older  people’s 
long-term care needs are not sustainable in view of this major demographic shift. This paper 
has tried to highlight ways of responding to this challenge by reducing the need for long-term 
care  through  prevention,  rehabilitation  and  the  creation  of  more  age-friendly  environments, 
and by developing more efficient ways of delivering care. 

Social innovation and social investment are called for to develop new ways of closing the gap 
between long-term care needs and provision. This paper presents some promising examples of 
good  practice  from  a  range  of  Member  States.  The  EU  can  play  a  major  role  in  promoting 
innovation  and  social  investment  in  this  area,  e.g.  through  the  European  Innovation 
Partnership  on  Active  and  Healthy  Ageing  and  the  Ambient  Assisted  Living  Programme.  It 
can  mobilise  the  structural  funds  for  boosting  investment  in  age-friendly  environments  and 
more qualified professional carers. 

Progress towards financially sustainable and socially adequate social protection against long-
term  care  risks  should  continue  to  be  monitored  by  the  EU’s  Economic  Policy  and  Social 
Protection Committees. A successful response to the challenges of rapid growth in the number 

EN 

27 

   EN 

 
of people aged 80 or over will be crucial for the dignity and quality of life of older people and 
their relatives. It will also be decisive for achieving a number of goals set in the context of the 
Europe  2020  Strategy  —  sound  public  finances  in  ageing  societies,  a  high  level  of 
employment and the reduction of poverty. 

It  is  therefore  suggested  that  future  work  with  Member  States  on  LTC  gives  particular 
attention  to  a  social  investment-oriented  strategy,  which  combines  preventive  measures  of 
healthy and active ageing with productivity drives in care delivery and measures to increase 
the ability of older men and women to continue independent living even as they become frail 
or  develop  disabilities.  Moreover,  as  increasing  priority  is  given  to  the  quality  of  public 
expenditure in EU policy guidance through Country-Specific Recommendations, these should 
also  focus  on  improving  the  effectiveness  of  spending  in  this  area,  so  adequate  social 
protection against long-term care risks can be ensured even at the height of population ageing. 

EN 

28 

   EN 

 
9. 

ANNEX 

ACTION programme, Sweden 

The  ACTION  programme  (Assisting  Carers  using  Telematics  Interventions  to  meet  Older 
people’s  Needs)  is  directed  towards  frail  elderly  persons  who  prefer  to  stay  in  their  own 
homes, but are in need of support. 

The ACTION service aims to strengthen the self-management capabilities of older people and 
their families. By means of ICT, family carers can get on-demand support from local service 
centres  staffed  with  qualified  professionals.  The  service  primarily  helps  informal  family 
carers. Also, networking and mutual exchange between service users is facilitated. 

The service offers information, education and support to older people and their family carers 
via the following channels: access to an extensive information database about caring in daily 
life, services available and coping strategies; physical and cognitive training programmes and 
relaxation  programmes;  support  and  social  company  from  other  users  via  the  integrated 
videophone  system;  support  and  advice  from  skilled  care  practitioners  working  in  the  call 
centre via the videophone system; individual and group computer education about how to use 
the ICT-based service; and comprehensive education, ongoing supervision and a certification 
programme  for  care  practitioners  working  in  an  ACTION  call  centre.  The  main  outcome  of 
this service is a strong improvement in quality of life, reduction of isolation of the patient and 
the carers, the improvement of carers’ preparedness, and therefore reduction in the need for 
home help services and delayed entry to nursing homes. The service is available to carers in 
several municipalities at a low price53. 

Examples of prevention 
Prevention through the ‘Re-ablement’ approach in the UK54 aims to maximise independence 
and  quality  of  life  in  older  age,  while  reducing  costs,  by  aiming  for  the  lowest  appropriate 
level  of  care  for  individuals.  Key  principles  are:  encouraging  individuals  to  do  things  for 
themselves, focusing on real practical outcomes within a specified timeframe, and continuous 
rather than one-off assessment to decide on individual care needs (Allen and Glasby, 2009). 
One  retrospective  longitudinal  study  demonstrated  that  an  average  of  60  per  cent  of  people 
leaving homecare re-ablement no longer required a homecare package and, 24 months later, 
had still not required a homecare package. 

Recently, the UK Department for Work and Pensions (DWP) put in place the LinkAge Plus 
programme,  a  scheme  worth  £ 10  million  to  improve  the  wellbeing  of  older  people  through 
promoting  stronger  partnership,  better  information  and  access  to  services,  and  putting  older 
people  at  the  forefront  of  service  design  and  delivery.  The  LinkAge  Plus  principles  can  be 
replicated in a variety of contexts. Case studies demonstrate the potential of the approach and 
a business case has been developed55, Taking falls as an example, on average, a fall resulting 
in  a  hip  fracture  costs  around  £ 20 000  to  the  taxpayer.  Evidence  suggests  that  15  weeks  of 
balance  classes  reduces  the  likelihood  of  a  participant  falling  by  around  50  per  cent.  This 
illustrative  example  suggests  that  each  £ 1  spent  on  balance  classes  by  the  taxpayer  in 

53  
54  

55  

The Telecare Development Programme in Scotland 2006-2011, (2011) New Heaven Research. 
CSED Homecare Re-ablement Retrospective Longitudinal Study, Social Policy Research Unit (SPRU), 
University of York, Acton Shapiro research organisation. 
Watt P. and Blair I. (2009). 

EN 

29 

   EN 

 
 
                                                 
LinkAge  Plus  areas  could  yield  health  and  social  care  savings  of  £ 1.35  plus  benefits  to  the 
individual of around £0.90, from improved longevity and quality of life. Combining the costs 
and  benefits  of  these  services  with  a  holistic  approach  to  service  delivery  increases  the  net 
present value in the example to £ 2.65 per £ 1 invested. 

Examples of health promotion 

Based on existing successful experiences over the last decade, the UK NHS created in 2011 
the  New  Medicine  Services56  (NMS,  October  2011  until  March  2013)  to  provide  early 
support to long-term care patients, to avoid inappropriate medication and to maximise positive 
benefits to clients. At this stage, the evidence suggests that the NMS will deliver net benefits 
of at least £ 210 million (discounted) in the worst-case scenario (i.e. highest cost and lowest 
benefit)  over  a  10-year  period.  This  is  purely  in  cash  terms,  and  does  not  consider  the 
potential wider health and economic benefits of the NMS, or the notion that £ 1 saved from a 
health intervention is worth £ 2.40. In the central scenario, net benefits are estimated at £ 1.5 
billion (discounted) over a 10-year period. 

Examples of rehabilitation 
Germany:  CARITAS  Bremen57  has  developed  a  rehabilitative  approach  as  part  of  a 
programme  that  aims  to  support  people  moving  back  home,  with  the  help  of  a  ‘bridging 
person’  (‘Pflegeüberleitungsperson’).  An  innovative  integrated  care  contract  provides 
extended rehabilitative training, e.g. after acute hospital admission, to restore the mobility of 
older people and help them regain their autonomy and better cope with disabilities. The care 
unit  is  located  in  a  care  home,  close  to  the  department  of  physiotherapy,  logo-therapy  and 
occupational therapy. Following the programme, home care is available for up to seven days 
after discharge. 

investigated 

the  potential 

Productivity and capacity gains from innovation including through use of ICT 

9.1. 
The  CARICT  project58  has 
information  and 
communication technologies (ICTs) on formal and informal carers by looking at experiences 
from  a  number  of  Member  States.  It  documents  that  ICTs  can  offer  a  cost-effective  way  to 
improve  the  quality  of  care  provided  to  dependent  older  people.  ICT  installations  providing 
monitoring  and  assistive  aids  may  allow  people  in  need  of  care  to  carry  on  with  daily  life 
activities without recourse to continued formal or informal care. Key factors for success are 
care coordination, personal support and social integration. The project also documents that the 
burden  on  care-givers  can  be  substantially  eased  by  offering  access  to  training  about  health 
and care issues and care-giving to frail people. 

impact  of 

56  

57  

58  

Introduction  of  the  New  Medicine  Service  (2011),  Department  of  Health,  Impact  Assessment  5101, 
from http://www.legislation.gov.uk. 
Kümpers S, et al., (2010) Prevention and rehabilitation within long-term care across Europe, European 
Overview Paper. 
JRC (2013) Can technology-based services support long-term care challenges in home care? Analysis 
of Evidence from Social Innovation Good Practices across the EU: CARICT Project Summary Report. 
Authors: Carretero, S.; Stewart, J.; Centeno, C.; Barbabella, F.; Schmidt, A., Lamontagne- Godwin, F. 
and  Lamura,  G.  JRC  Scientific  and  Technical  Reports  Series,  EUR  25  695  EN,  at: 
http://ipts.jrc.ec.europa.eu/publications/pub.cfm?id=5899. 

EN 

30 

   EN 

 
 
 
                                                 
Telecare59 in Scotland covers a range of devices and services that use technology to enable 
people to live with greater independence and safety in their own homes. 

Examples include devices that trigger a response from a call centre, such as falls monitors and 
motion sensors. The responses may range from a phone call to the person, to alerting a local 
carer,  neighbour  or  social  service  or  alerting  emergency  services  if  appropriate.  Other 
examples include devices that directly alert the person in the home to a particular hazard, such 
as  a  water-level  monitor  in  a  bath.  IT  developments  are  continually  extending  the  range  of 
devices and services available and, as a result, there is much scope for telecare to help older 
people with particular health and social care needs to remain in their own homes and optimise 
their  independence  and  quality  of  life.  Telecare  (2006-2011)  involved  investments  of  £ 20 
million,  and  is  estimated  to  have  saved  approximately  £ 80  million.  Nearly  half  of  these 
savings arose from avoiding care home admissions, while a similar figure arose from avoiding 
hospital in-patient stays. Clients and carers are referred to telecare by social services and/or by 
social workers or health professionals. The trial period achieved its aims to increase the use of 
telecare  in  mainstream  service  provision,  improve  assessment  procedures  for  service  users, 
train  service  providers’  staff  to  incorporate  telecare  within  care  packages,  ensure  telecare 
services  are  delivered  to  recognised  standards,  and  enhance  innovation  in  telecare  services. 
The  Scottish  government  is  now  implementing  a  new  telecare/telehealth  initiative  running 
from  2012-2015,  called  Delivering  Assistive  Living  Lifestyles  at  Scale.  This  is  intended  as 
phase  one  of  the  wider  Scottish  Assisted  Living  Programme,  which  will  utilise  new 
technologies to support people with health and social care needs in their own homes. 

E-Care60  is  as  a  pro-active  case  management  service  in  operation  since  2005  in  Italy.  The 
main objective of the E-Care project is to maintain independent living for the elderly in their 
own homes through customised care plans designed according to individual needs. E-care is a 
service organised as a 24-hour/7-days-a-week call centre that offers a wide range of services 
targeting  physically  frail  or  socially  isolated  elderly  people  aged  75+  living  at  home.  The 
service  provides  older  people  with  information  on  health,  social  care  and  social  alarm 
services. A call centre functions as an intermediary between the frail elderly and social and 
health care providers. On a regular basis, an operator contacts the elderly to check their well-
being,  health  conditions  and  needs.  In  the  case  of  a  problem,  the  operator  and  the  patient 
decide together upon the action to take: intervention of a doctor or a volunteer organisation 
for social support. A unique electronic file records the basic individual history and a software 
platform allows for information-sharing and data transfer between care services. The E-Care 
platform has also been used to integrate services such as: 
- Uffa che Afa’ — an initiative set up to support vulnerable people during severe heat waves 
- a tele-geriatrics service to support people who need care after hospital discharge 
- a dementia-specific telecare service 
- the ‘Giuseppina’ service, which provides free home delivery of food and medication as well 
as transport services to hospitals or social events 
E-care has reduced the number of hospital admissions and led to a decrease of 50 % in users 
accessing hospital services. 

59  
60  

See: http://www.scotland.gov.uk/Publications/2010/10/27154413/6. 
See: http://www.ict-ageing.eu/index.php?s=E-care+Project. 

EN 

31 

   EN 

 
 
                                                 
Quality assurance in LTC 
Framework  for  the  Prevention  of  Elder  Abuse  and  Neglect61:  The  Netherlands  has 
implemented an ambitious and very comprehensive legal and institutional framework to fight 
elder abuse. The framework covers all stakeholders and most dimensions of the phenomenon 
through initiatives in 10 areas: 

1:  Prevention  (guide  for  municipalities  on  preventing  elder  abuse,  including  a  special 
initiative on financial exploitation) 
2: Targeted information and awareness-raising for older people on elder abuse 
3: Screening of paid care staff, including via mandatory certificates of conduct (VOG) 
4: Toolkit on volunteers and elder abuse (awareness raising and guidelines for conduct) 
5:  Reporting  elder  abuse  to  authorities  (mandatory  for  abuse  by  professionals,  mandatory 
protocolling of abuse in home environments, specific guidelines) 
6: E-learning, training and education of care staff (in collaboration with trade unions etc.) 
7: Elder-abuse hotlines (established in centres for reporting of domestic violence etc.) 
8: Aid and support for victims following a report of neglect or abuse 
9: Support for victims of disruptions in informal care 
10: Approach to perpetrators (principles for handling abuse cases: a serious offence requiring 
a  legal  approach  entailing  intensified  monitoring  of  reported  elder  abusers;  moreover,  if 
professional care staff commit elder abuse, the IGZ Assessment Framework stipulates that the 
care  institution  must  suspend  the  offender  and  that  a  report  of  criminal  activities  should  be 
filed with the public prosecution service, where appropriate. 

61  

See: http://www.preventelderabuse.eu/european/Multimedia/Get/186. 

EN 

32 

   EN