Long-term care settings for older people in Europe: a comparative overview

A new report by the European Social Policy Analysis Network (ESPAN) examines long-term care (LTC) settings for older people in 38 countries: the 27 EU countries, nine (potential) candidate countries, as well as Iceland and Norway. The report aims to gain a better understanding of the variety and prevalence of LTC settings for people aged 65+ across Europe.

Drawing on national reports prepared by the 38 ESPAN country teams, the report provides:

• a comparative overview of formal LTC, describing residential care, home care and community-based care settings, their key characteristics, geographical imbalances and emerging "hybrid" or innovative care models
• a critical assessment of how the organisational structure, governance and funding of LTC systems shape the availability of different care settings and the real scope for personal choice
• a review of recent and ongoing LTC reforms

For the 27 EU countries, it also presents a selection of key comparative indicators, context information and policy levers on LTC included in the EU Monitoring Framework for the Council Recommendation on access to affordable high-quality LTC (covering expenditure, affordability and availability of LTC services, as well as the LTC workforce and informal care).

The report concludes with policy pointers for expanding and diversifying LTC service provision, enhancing governance and quality, improving affordability, addressing funding challenges and regional disparities, and modernising LTC through technology and innovation.

Some key findings

• All EU countries provide residential care, home care and community-based care services, with a strategic shift in most of them from institutional models towards more person-centred and community-based approaches, including technology-enabled options. However, the mix of services and their practical implementation vary substantially across countries.
• Access to residential care, home care and community-based care services varies not only between but also, sometimes considerably, within EU countries.
• Almost all EU countries are developing innovative and hybrid approaches to LTC that integrate residential care, home care and/or community-based care components, and prioritise autonomy, social inclusion and continuity of care as well as person-centred care.
• In many EU countries, care arrangements are more often shaped by constraints (such as limited service availability, territorial disparities, workforce shortages and affordability barriers) than by the preferences of older people and their families.
• In most EU countries, a key structural challenge for LTC systems is the fragmentation of responsibilities between different levels of government and between the health and social sectors. This may affect care pathways, widen geographical inequalities, and shift more costs onto users and carers - thereby increasing reliance on informal care or undeclared work.
  

Background

The ageing population in the EU is putting increasing pressure on social protection systems, driving up demand for LTC and exposing gaps in existing provision. The number of people in the EU in need of LTC is projected to increase from 30.8 million in 2019 to 38.1 million in 2050. In 2022, the average EU public expenditure on LTC stood at 1.7% of GDP, with significant variation in spending levels and in the balance between residential services, home care and cash benefits. Many older people still rely heavily on informal carers, whose personal, financial, and health burdens are often not reflected in policy design or in statistics and monitoring.

Data from the EU Monitoring Framework also reveal uneven coverage of formal services, significant disparities in the affordability of professional home care and in the staffing ratios across EU countries, as well as substantial unmet needs.

Together, these trends point to the need for a more coherent, person-centred mix of LTC settings to enable older people to remain in their own homes and communities for as long as possible, while ensuring equitable access to high-quality care.

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