Transcript A comparative analysis of long-term care for older people

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, 1995-2005
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 1950 - 2005
Population Changes: Natural Growth, Overall Growth, Migration 1950 - 2005
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
Source: UNDESA/Population Division, Living arrangements of Older Persons Around The World (2005).
*EU 27 minus Luxembourg, Malta and Slovakia.
26
Home alone...even more so for the 80+
Living alone for people aged 60-79 and those aged 80+, Eurostat 2001 Census
data
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.
27
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)
Labour
of love
“Intimité à
distance”
Source: Huber et al. (2009, forthcoming) Own calculations based on Walker
(1999).
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
Regardless of
„care regimes“
Source: National sources, OECD (2005) and EUROFAMCARE national reports.
39
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
Source: EUROFAMCARE national reports.
41
Family Affair:Who Cares?
Children, Partner, Others?
Relationship between the carer and the care recipient in percentage
Source: OECD (2005), national sources and EUROFAMCARE national reports.
42
Overburdened Family Carers
EUROBAROMETER (2007) In your opinion, do dependent older people rely too much on their relatives?
Lack of care
services…
Providing care
to co-residents…
… explaining
carers’ burden?
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 distribution of carers in %
EU 15
BE
44 and Less
NL
45-64
65+
IE
DE
AT
Age and Gender
Distribution of
Carers in %
0
20
40
60
80
100
Gender distribution of carers in %
EU 15
BE
Female
NL
Male
IE
DE
AT
Sources: AT- ÖBIC, DE- TNS Infratest, IE- CSO,
NL- SCP Office, BE- PSBH Wave 10, EU 15- ECHP.
0
20
40
60
80
100
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?
DK
Own home by a relative
PL
FR
Own home by a professional
care service
ES
Own home by a personal
hired carer
AT
Home of a close family
member
DE
In a long-term care
institution
EU27
0
20
40
60
80
100
Source: EUROBAROMETER, 2007: 97
What would be the best option for people in need of LTC?
Selected countries, in %
AT
UK
SE
FI
PL
NL
FR
ES
DE
EU27
0
10
20
30
40
50
60
70
80
90
They should live with one of their chilren
One of their childrenshould regularly visit them
They should use public and private home care
They should move to a nursing home
100
Source: EUROBAROMETER, 2007: 97
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
100
90
80
70
60
50
40
30
20
10
Wish to work or to work more (and reduce caring time)
Wish to work less to have more time for caring
Source: EUROSTAT LFS, Ad-hoc module
Note: women aged 15-64
Cyprus
Denmark
Slovenia
Romania
Bulgaria
Greece
Hungary
Czech Republic
Slovakia
Poland
Portugal
Latvia
Italy
Belgium
Ireland
United Kingdom
Norway
Spain
Sweden
Austria
Luxemburg
Germany
Netherlands
France
0
Worktime Flexibility / Rigidity
Full-time working women (prime age) who can vary the
start / end of working day for family reasons, 2005
100%
90%
80%
70%
60%
50%
Not possible
Rarely possible
40%
30%
20%
10%
Bu
lg
G ar i
er a
m
Sl any
ov
ak
ia
Ita
Es ly
to
ni
Cz
ec Fr a
h an
Re ce
pu
Po blic
rtu
Sl ga l
ov
e
Sw nia
ed
Un
en
ite
S
d
Ki pain
ng
d
Be om
lg
iu
Au m
De stria
Ne nm
th ark
er
la
nd
s
0%
Source: EUROSTAT LFS, Ad-hoc module
Note: Women aged 20-49
Generally
possible
Romania
Worktime
Rigidity
Full-time working
women (prime age)
who can vary the
start / end of
working day for
family reasons, 2005
16.6
57.4
Cyprus
20.5
Lithuania
21.3
32.3
53.0
Malta
22.8
51.3
Poland
23.5
Bulgaria
24.1
45.7
47.5
Germany
30.4
Slovakia
30.7
45.9
43.3
Greece
33.3
27.2
Italy
33.7
26.0
Estonia
34.1
Hungary
34.5
France
35.2
Czech Republic
23.0
36.8
24.1
38.2
Portugal
28.0
41.4
40.6
EU15
43.4
Latvia
43.6
Slovenia
29.8
23.4
48.4
Sweden
18.9
51.9
26.2
Spain
53.8
United Kingdom
54.7
26.1
31.8
Norway
59.5
Finland
59.7
Belgium
60.9
Austria
27.9
20.0
23.2
62.6
Denmark
22.3
64.6
Luxemburg
22.5
68.3
Netherlands
90.7
0%
Source: EUROSTAT LFS, Ad-hoc module
Note: Women aged 20-49
23.9
10%
20%
30%
40%
Generally possible
50%
5.6
60%
Rarely possible
70%
80%
Not possible
90%
100%
Beneficiaries of Formal Home Care Services
Home Is Where You’re Cared For
Share of older people receiving long-term care services at home (most recent date)
Highly different
approaches to
home care
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
More women survive to
old-age than men
Gender ratio at the age of 65 (2006)
Source: Eurostat, UNECE, UNPP.
More women than men receive
care: the case of home care
Share of women among 65+ beneficiaries of home care
(2007 or most recent date)
Source: Own calculations based on national sources, OECD and
Eurostat demographic data, Huber et al. (2009, forthcoming).
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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?
Share of older people receiving care in institutions (most recent date)
Institutional care
covers only a very
small percentage of
older people
6.5%
Source: Huber et al. (2009) Own calculations based on OECD, NOSOSCO , WHO, Eurostat and national sources.
Providing Care at Home or in Institutions
Share of older people receiving care at home and in as institutional setting (most recent date)
Publicly provided
care at home:
the key for wider
access to care
Source: Own calculations based on OECD, NOSOSCO , WHO, Eurostat and national sources.
Women Much More Likely in (Institutional) Care?
Gender index for 65+ beneficiaries of institutional care (2007, or
most recent date)
Gender index – captures
differences that do
not arise from
demographics alone
Answer: yes, women are
much more likely to
receive care, specially
institutional care
Source: Own calculations based on national sources, OECD and Eurostat
demographic data, Huber et al. (2009)
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?
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)
69
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 expenditure on long-term care and its distribution between home and institutional care (most recent date)
Paradox:
most people
cared for at
home...
... most public
resources
devoted to
institutional
care
Public resources:
 A diverse picture
 Modest amounts
dedicated to care:
EU15 spends 7.6%
on health and 9.1%
on old-age pensions
alone
Source: Huber et al. (2009) Own calculations based on OECD, NOSOSCO , Eurostat and national sources
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
Relation between expenditure on old-age institutional care and share of older people benefiting from it, 2007
Different
private public
mixes in
expenditure
Differences in
quality
Source: Huber et al. (2009) Own calculations based on OECD, NOSOSCO, Eurostat and national sources.
Sharing the Burden: Private / Public Expenditure Mix
Private expenditure on long-term care (% of GDP) and its distribution (2007 or most recent date)
• Private
expenditure: copayments;
means-testing;
supplementary
payments;
• Different publicprivate 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)
78
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?
User’s fee for institutional care, in percentage of the APW net wage (2007*)
Paying for
institutional care
(EU level):
51.2% of public
resources devoted
to 3.3% of 65+...
... yet, heavy
private
contributions still
required.
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*)
Trade-offs in Generosity – Attendance Allowances
Amounts of attendance allowances in percentage of net wage of APW and its
beneficiaries (2007 or most recent date)
Higher but targeted
amounts
„Too generous“?
„Everyone gets
by with little“
Source: Huber et al. (2009)
85
Long-term care financial flows: Austria
Bund
Bundespflegegeld
Bundesländer
Nettoausgaben für
stationäre und
ambulante Pflege
Landespflegegeld
1,5 Mrd €
Sonstige
1 Mrd €
300 Mio €
350 Mio €
Pflegebedürftige Menschen
1,8 Mrd €
340 Mio €
310 Mio €
90 Mio . €
Alten-, Pflege und
Behindertenheime
1,74 Mrd €
70 Mio €
private Einnahmen
(Pensionen etc.)
30 Mio €
Soziale Dienste
500 Mio €
50 Mio . €
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 challenges
interest 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
Overcoming
barriers
Nurs
Gener
ing
al
Hospital
Hom
Practiti
e
oner
Care
Short Day
term Care
Care
Other
Home Services,
Help Housing,
etc.
Resident
ial Care
Health Care System
differentiated,
professionalised, hierarchical,
Social Care System
funded, rights-based
local, less professionalised,
badly funded, discretional
An Example of Good Practice
Skævinge (Denmark): The Health Centre ‘Bauneparken
24-hour integrated
health and social care
Short
term
Care
Hospital
General
Practitio
ner
Day
Care
Nursin
g
Home
Care
Home
Help
How:
 Person-centred
 Single point of contact
 Case management
 Self-care and
prevention
Other
Services,
Housing, etc.
Residential
Care
Outcomes:
 No waiting time
 Room for
specialized
services
 Reduced
hospital stays
 Below average
use of resources
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