Main Challenges Facing Long-term Care Bernd Marin, European Centre Vienna Presentation at the SZMI / European Centre Vienna Conference „Long-term care in Europe –discussing trends and relevant issues“ Budapest, 22 / 23 February 2010

Demography and Health

Life Expectancy at Birth and at 20, 60, 65 and 80 years*, 2003 *Life expectancy is a measure of mortality in the given calendar year

Survival Rates up to Age 20, 60, 65, 80,

The 80+ have become the fastest growing segment in the population Share of the population aged 80+, 1990 ‑ 2006

Also people 80 years old can expect to life ever longer Life expectancy at age 80, 2006, and its gains since 1990

Gains in life expectancy continue at the age of 80 and beyond Evolution of life expectancy at age 80 and its distribution among countries, 1990 and 2006

Women outlive men, even at higher ages Difference in life-expectancy at age 65 and 80, by gender, 2006

More or less of a woman’s world in Third Age (65+, 80+) Gender ratio at the age of 65 and 80, 2006

Population ageing 65+ is expected to accelerate in the next decades Current and projected share of the population aged 65+, 2006 and 2050

The future importance of the 80+ Current and projected share of the population aged 80+, 2006 and 2050

Future Ageing in the Age Groups 80+ Current and projected share of the population aged 80+, 2006 and 2050 (selected countries) Huber et al. (2009) based on Eurostat EUROPOP2008.

Most people stay relatively healthy up to the age of 75 – 80 years Self-reported severe activity restriction, by gender and age-group, 2006

After the age of 85, one in four persons suffer from dementia – 75% not Prevalence rates of dementia, by age group and gender, 2005

Uncertain improvements in old-age severe disability – Diminishing disability trends Trends in severe disability among older people

Uncertain improvements in old-age severe disability – Inconclusive, stable and rising disability trends Trends in severe disability among older people

Population Changes: Natural Growth, Overall Growth, Migration

Living Arrangements of Older People

La vie à deux? Large differences around the globe Living arrangements of people aged 60+ around the World, UN 1990s Census Round

Gender and regional differences in living arrangements Differences in living arrangements between men and women aged 60+, UN 1990 and Eurostat 2001 Census Round

Where will I live? High mobility in later life European preferences after retirement

Home alone? Proportion of people aged 60+ who live alone, UN 1990s Census Round 26 Source: UNDESA/Population Division, Living arrangements of Older Persons Around The World (2005). *EU 27 minus Luxembourg, Malta and Slovakia.

Home alone...even more so for the 80+ Living alone for people aged and those aged 80+, Eurostat 2001 Census data 27 Source: UNDESA/Population Division, Living arrangements of Older Persons Around The World (2005); Eurostat 2001 Census data; National sources for Israel. *EU 27 minus Belgium, Bulgaria, Latvia, Luxembourg, Malta and Sweden.

Single person households across the globe - and within Europe Proportion (%) of persons aged 60+ who live alone: by region and by sex, UN 1990s Census Round

Universal trend across the globe: a tendency towards living alone Proportion of people aged 60+ living alone at two points in time by sex, averages for major areas

Two is company...but less so for women aged 80+ Living as a couple only for people aged 60+, Eurostat 2001 Census data

Moving back in: people aged 60+ living together with their children Older people living with children, data for the 60+, Eurostat 2001 Census data

Informal Care

A Large Diversity of Informal Care Giving in EU15 - Mostly to Non Co-residents Percentage of the population aged 15+ providing informal care to a relative aged 60+, 1999

“Intimité à distance” in the North: a Low Share of Co-resident Informal Carers Percentage of the population aged 15+ providing informal care to a relative aged 60+, 1999

Diversity in Informal Care to Co-residents Percentage of the population aged 15+ providing informal care to a co-resident relative aged 60+ (1999) Source: Huber et al. (2009, forthcoming) Own calculations based on Walker (1999). “Intimité à distance” Labour of love

Differences Across Europe in Filial Obligations for One’s Older Relative Reasons for stopping caring after 1 year (excluding elder’s death)

What is Best for Your Parent ? Adult Children’s Perspectives: Divergences Across Europe

Portrait of Informal Carers Partners and Children most common informal carers Women predominant as carers (both formal and informal), never below 70% Men take care of partner above all other relative and usually take on caring tasks at a later stage 38

Who provides care for dependent older people within the family ? It’s a woman’s world… Family carers by gender and country 39 Regardless of „care regimes “ Source: National sources, OECD (2005) and EUROFAMCARE national reports.

Heavy care work for older relatives: It’s even more a woman’s world

...but men catch up in later years Women provide more care to older people but men catch up in later years 41 Source: EUROFAMCARE national reports.

Family Affair:Who Cares ? Children, Partner, Others? Relationship between the carer and the care recipient in percentage 42 Source: OECD (2005), national sources and EUROFAMCARE national reports.

Overburdened Family Carers Lack of care services… Providing care to co-residents… … explaining carers’ burden? EUROBAROMETER (2007) In your opinion, do dependent older people rely too much on their relatives? Source: EUROBAROMETER (2007)

Informal Care as Mid-life Challenge Providing care for older family members by country and age group Source: OECD (2005), EUROFAMCARE national reports.

Age and Gender Distribution of Carers in % Sources: AT- ÖBIC, DE- TNS Infratest, IE- CSO, NL- SCP Office, BE- PSBH Wave 10, EU 15- ECHP.

Who Cares? The Ageing of Informal Caregivers Between 1994 and 2006

Changing Expectations and Preferences? In which way do you expect to be looked after if in need of care?

What would be the best option for people in need of LTC? Selected countries, in %

Labour of Love Family help as a percentage of help to people aged 75+ by country and domain, 2000/2001

Changes in the Family Situation as Reflected in the Workplace of Main Carer

Reconciling Work & Care - Impossible? Employment status of main carers by country and domain Source: National sources, EUROFAMCARE national reports, Lamura et al. (2006).

Work & Care Preferences Employed women who wish to change the organisation of their working life and care responsibilities, 2005 Source: EUROSTAT LFS, Ad-hoc module Note: women aged 15-64

Worktime Flexibility / Rigidity Full-time working women (prime age) who can vary the start / end of working day for family reasons, 2005 Source: EUROSTAT LFS, Ad-hoc module Note: Women aged 20-49

Worktime Rigidity Full-time working women (prime age) who can vary the start / end of working day for family reasons, 2005 Source: EUROSTAT LFS, Ad-hoc module Note: Women aged 20-49

Beneficiaries of Formal Home Care Services

Home Is Where You’re Cared For Highly different approaches to home care Share of older people receiving long-term care services at home (most recent date) Source: Huber et al. (2009) Own calculations based on OECD, NOSOSCO, WHO, Eurostat and national sources.

The Majority of Beneficiaries are Cared for at Home in Most European Countries Share of those aged 65+ who receive long-term care services at home and in institutional settings (most recent date )

Moving Towards More Home Care, Staying Put or Increased Institutionalisation During Last Decade Share of 65+ beneficiaries cared for at home (evolution from the mid 1990s till most recent date)

Stating Preferences Across Europe: Most Would Like to Be Cared in Their Own Homes Question 20b: If you personally became dependent on long-term care, how would you prefer to be looked after?

Do Different Approaches in Providing Cash for Care Produce Different Outcomes? Beneficiaries (65+) of cash for care allowances in percentage of 65+ population (2007*)

Women Majority in the Population - and in Home Care 61 More women than men receive care: the case of home care More women survive to old-age than men Source: Eurostat, UNECE, UNPP. Gender ratio at the age of 65 (2006) Source: Own calculations based on national sources, OECD and Eurostat demographic data, Huber et al. (2009, forthcoming). Share of women among 65+ beneficiaries of home care (2007 or most recent date)

The Majority of Beneficiaries of Home Care Services are Women Share of women among 65+ beneficiaries of home care (2007*)

Women Are Disproportionately Represented in Home Care Services… or Not That Much? Gender Index of Old-Age Beneficiaries 2007

Beneficaries of Institutional or Residential Care

Only 1 in 30 Older Persons Receiving Care in Institutions? 6.5% Institutional care covers only a very small percentage of older people Share of older people receiving care in institutions (most recent date) Source: Huber et al. (2009) Own calculations based on OECD, NOSOSCO, WHO, Eurostat and national sources.

Providing Care at Home or in Institutions Publicly provided care at home: the key for wider access to care Share of older people receiving care at home and in as institutional setting (most recent date) Source: Own calculations based on OECD, NOSOSCO, WHO, Eurostat and national sources.

Source: Own calculations based on national sources, OECD and Eurostat demographic data, Huber et al. (2009) Gender index for 65+ beneficiaries of institutional care (2007, or most recent date) Women Much More Likely in (Institutional) Care? Gender index – captures differences that do not arise from demographics alone Answer: yes, women are much more likely to receive care, specially institutional care 67

Over-Representation of Women in Institutional Care Increases with Age Gender index for beneficiaries of institutional care aged 65+ and 80+, by age groups (2007*)

Living Alone Explaining the Institutionalisation of Women? 69 Living alone is positively related to institutionalisation… … but not to receiving formal care at home Source: Own calculations based on OECD, Eurostat and national sources. Huber et al. (2009)

The 80+ Have Higher Chances - and Needs - of Receiving Formal Care Share of population in age-groups benefiting from home care (2007*) and institutional care (2007*)

Institutional Care is Targeted to the 80+ Age-index (targeting between 65 – 79 and 80+) for old-age beneficiaries of home care (2007*) and institutional care (2007*)

Privacy in Residential Care Where dignity of care and quality of living come together Percentage of people living in rooms (institutional care) by number of beds per room Source: National sources and OECD (2005)

Expenditure and Financing: Fiscal Sustainability of Care

How Much and Where Are We Spending? Large Differences in Public Expenditure, both in Scope and Structure of Spending Public resources:  A diverse picture  Modest amounts dedicated to care: EU15 spends 7.6% on health and 9.1% on old-age pensions alone Paradox: most people cared for at home most public resources devoted to institutional care Source: Huber et al. (2009) Own calculations based on OECD, NOSOSCO, Eurostat and national sources Public expenditure on long-term care and its distribution between home and institutional care (most recent date)

Not ageing per se but formal care recipiency as cost driver in LTC spending levels Ageing and public expenditure on long-term care, 2007 Source: Huber et al. (2009) Own calculations based on OECD, NOSOSCO, Eurostat and national sources

Making Sense of Gaps in Public / Total Expenditure in Institutional Care Different private public mixes in expenditure Differences in quality Relation between expenditure on old-age institutional care and share of older people benefiting from it, 2007 Source: Huber et al. (2009) Own calculations based on OECD, NOSOSCO, Eurostat and national sources.

Sharing the Burden: Private / Public Expenditure Mix 78 Private expenditure: co- payments; means-testing; supplementary payments; Different public- private mixes; Means-tested = heavier burden? Institutional care: user’s fees are standard procedure. Source: Own calculations based on OECD, NOSOSCO and national sources. Huber et al. (2009) Private expenditure on long-term care (% of GDP) and its distribution (2007 or most recent date)

Most beneficiaries are cared for at home… but that’s not where most public money goes to Share of total beneficiaries and total public expenditure on institutional care, 2007*

The importance of cash for care allowances in public expenditure Public expenditure on cash for care allowances, 2007*

Generosity of attendance allowances differs substantially Attendance allowances’ amounts in percentage of the net wage of the APW (2007*)

Generosity of care allowances shows wide variation Care allowances’ amounts in percentage of the net wage of the APW (2007*)

Paying User Fees for Institutional Care How Deep is the Beneficiaries’ Pocket? Paying for institutional care (EU level): 51.2% of public resources devoted to 3.3% of yet, heavy private contributions still required. User’s fee for institutional care, in percentage of the APW net wage (2007*) Source: Huber et al. (2009) Own calculations based on national sources.

Trade-offs in Generosity in Care Allowances Care allowances’ amounts in percentage of net wage of the APW and its beneficiaries (2007*)

Amounts of attendance allowances in percentage of net wage of APW and its beneficiaries (2007 or most recent date) Source: Huber et al. (2009) Trade-offs in Generosity – Attendance Allowances 85 „Everyone gets by with little“ Higher but targeted amounts „Too generous“?

Long-term care financial flows: Austria Quelle: Arbeitskreis Pflegevorsorge, 2004; eigene Berechnungen Huber/Leichsenring, 2006

Long-term Care as an Emerging New Field in Health & Social Policy

Long-term Care in the EU Today  Long-term care: a late-comer in social protection systems  Diversity and common trends in the EU  Key policy challenges and good practices:  Better integration between health and long-term care  Improved access to care for dependent old-age people  Choice in publicly provided services  Long-term care workforce policies  Alzheimer diseases and other dementia  Quality of services, quality assessment/control/assurance  Instant JIT responsiveness, timeliness, delivery when needed  Ageing in place and grace: dignity, respect, TLC

Long-Term Care: a Late-Comer  “Young” subject  Arguably the social policy area where EU Member Countries differ the most  First steps as a differentiated policy field  Common challengesinterest in good practices  Key issues for developing long-term care in the EU:  Enhanced coordination/integration of health and social care;  User-oriented approach.

A Diversified Picture on Long-term Care Different approaches to long-term care – Cash benefits (Austria, Germany, Italy, Czech Republic); – Means-test (UK); – Public provision of care services (Sweden, Denmark). Hybrid rather than pure models of care – Cash benefits: within the tax envelope (Austria, Czech Republic) or through social insurance (Germany); – Regulated (France) and unregulated allowances (Italy); – Universal public provision of care (Denmark) or targeted “universalistic” provision of care (Sweden); – Provision of care (institutions): public (Sweden), private “for profit” (Spain, UK), private “non-profit” (Germany). 90

The Challenge of Coordination and Integration Health Care System differentiated, professionalised, hierarchical, funded, rights-based Social Care System local, less professionalised, badly funded, discretional Hospital Gener al Practiti oner Nurs ing Hom e Care Short term Care Home Help Other Services, Housing, etc. Resident ial Care Day Care Overcoming barriers

An Example of Good Practice Hospital General Practitio ner Nursin g Home Care Short term Care Home Help Other Services, Housing, etc. Residential Care Day Care Skævinge (Denmark): The Health Centre ‘Bauneparken How:  Person-centred  Single point of contact  Case management  Self-care and prevention Outcomes:  No waiting time  Room for specialized services  Reduced hospital stays  Below average use of resources 24-hour integrated health and social care

Having a Choice on Care Pathways to increased consumer choice:  Empowering people with a budget  Opening the care market to private providers Challenges:  Limits in using informal carers  Ensuring “market thickness”  Concentration of providers What have we learned from care markets?

Long-term Care Workforce  Long-term care workers are crucial for quality  Care services as a “job machine” However:  Concerns remain over labour shortages  Informal markets of care  Can immigration (“pink card regime”) fill the gap? Need for:  Increased skills  Better working and paying conditions