Who Cares? Care coordination and cooperation to enhance quality in elderly care in the European Union Prof. Dr. Bernd Marin Conference on Healthy and Dignified Ageing Swedish Presidency of the EU September 2009

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 15-16/09/2009 Conference on Healthy and Dignified Ageing – Swedish Presidency of the EU 2

Long-term care: a late-comer 15-16/09/2009 Conference on Healthy and Dignified Ageing – Swedish Presidency of the EU 3  “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.

How many receive care in institutions? 15-16/09/2009 Conference on Healthy and Dignified Ageing – Swedish Presidency of the EU 4 6.5% Institutional care covers only a small percentage of older people Share of older people receiving care in institutions (most recent date) Source: Huber et al. (2009 forthcoming) Own calculations based on OECD, NOSOSCO, WHO, Eurostat and national sources.

Home is where you’re cared for 15-16/09/2009 Conference on Healthy and Dignified Ageing – Swedish Presidency of the EU 5 Different approaches to care Share of older people receiving long-term care services at home (most recent date) Source: Huber et al. (2009 forthcoming) Own calculations based on OECD, NOSOSCO, WHO, Eurostat and national sources.

Providing more people with care 15-16/09/2009 Conference on Healthy and Dignified Ageing – Swedish Presidency of the EU 6 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.

Differences in informal care giving 15-16/09/2009 Conference on Healthy and Dignified Ageing – Swedish Presidency of the EU 7 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). Intimacy at a distance Labour of love

Overburdened carers 15-16/09/2009 Conference on Healthy and Dignified Ageing – Swedish Presidency of the EU 8 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)

Mid-life challenges 15-16/09/2009 Conference on Healthy and Dignified Ageing – Swedish Presidency of the EU 9 Providing care for older family members by country and age group Source: OECD (2005), EUROFAMCARE national reports.

Reconciling work and care 15-16/09/2009 Conference on Healthy and Dignified Ageing – Swedish Presidency of the EU 10 On an individual level: remains difficult On a policy level: can the Lisbon Strategy and support to carers co-exist? Employment status of main carers by country and domain Source: National sources, EUROFAMCARE national reports, Lamura et al. (2006).

How much and where are we spending? 15-16/09/2009 Conference on Healthy and Dignified Ageing – Swedish Presidency of the EU 11 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, forthcoming) 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)

Making sense of differences in expenditure 15-16/09/2009 Conference on Healthy and Dignified Ageing – Swedish Presidency of the EU 12 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 forthcoming) Own calculations based on OECD, NOSOSCO, Eurostat and national sources.

How deep is the beneficiaries’ pocket? 15-16/09/2009 Conference on Healthy and Dignified Ageing – Swedish Presidency of the EU 13 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 forthcoming) Own calculations based on national sources.

Trade-offs in benefit generosity 15-16/09/2009 Conference on Healthy and Dignified Ageing – Swedish Presidency of the EU 14 Higher but targeted amounts “Generous”? Smaller portions of the pie Amounts of attendance allowances in percentage of net wage of APW and its beneficiaries (2007 or most recent date) Source: Huber et al. (2009, forthcoming).

The challenge of coordination and integration 15-16/09/2009 Conference on Healthy and Dignified Ageing – Swedish Presidency of the EU 15 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 15-16/09/2009 Conference on Healthy and Dignified Ageing – Swedish Presidency of the EU 16 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

Accessing mainstream health 15-16/09/2009 Conference on Healthy and Dignified Ageing – Swedish Presidency of the EU 17  Dependent older people facing barriers in access  Major improvements should be possible in rehabilitation and mental health  Specialised research in health care for older people needed Mobility Gaps in geriatrician’s training Age discrimination Poverty Low expectations Regulations

Having a choice on care 15-16/09/2009 Conference on Healthy and Dignified Ageing – Swedish Presidency of the EU 18 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 15-16/09/2009 Conference on Healthy and Dignified Ageing – Swedish Presidency of the EU 19  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 fill the gap? Need for:  Increased skills  Better working and paying conditions

Alzheimer and other dementia 15-16/09/2009 Conference on Healthy and Dignified Ageing – Swedish Presidency of the EU 20 Why Alzheimer and other dementia matter? Improved dementia assessment and care… … but tailored training of carers and improved early detection is still needed Prevalence of dementia in Europe, by age-groups (2005) Source: Alzheimer Europe (2006) based on Ferri et al. (2005).

Privacy in care home 15-16/09/2009 Conference on Healthy and Dignified Ageing – Swedish Presidency of the EU 21 Where dignity of care and quality of living come together Percentage of people living in rooms (institutional care) by number of beds per room Percentage of people living in rooms (institutional care), by number of beds per room Source: National sources and OECD (2005)

Future ageing in the older age groups 15-16/09/2009 Conference on Healthy and Dignified Ageing – Swedish Presidency of the EU 22 Current and projected share of the population aged 80+, 2006 and 2050 (selected countries) Huber et al. (2009) based on Eurostat EUROPOP2008.

Ageing and public expenditure in long-term care 15-16/09/2009 Conference on Healthy and Dignified Ageing – Swedish Presidency of the EU 23 Ageing and public expenditure on long-term care, 2007 Source: Huber et al. (2009, forthcoming) Own calculations based on OECD, NOSOSCO, Eurostat and national sources.

Trade-offs in benefit generosity 15-16/09/2009 Conference on Healthy and Dignified Ageing – Swedish Presidency of the EU 24 Amounts of care allowances in percentage of net wage of APW and its beneficiaries (2007 or most recent date) Source: Huber et al. (2009, forthcoming).