Significant demographic shifts are taking place in Europe. As life expectancy continues to rise, more people are living longer, especially those aged 80 and above. Declining fertility rates are contributing to an ageing population: with fewer births, there are fewer younger people to replace and support the older generations. While migration may help alleviate some of these effects, it cannot fully reverse them. The social implications are also profound and include shifts in household and family structures, as well as caregiving dynamics, with fewer children and extended families available to care for older individuals. Against this backdrop, long-term care (LTC) systems play a crucial role. Public services across Europe vary significantly in terms of governance, structure, financing, and delivery – ranging from highly integrated systems in some countries to fragmented provisions in others. High-performing systems benefit from substantial public investment and comprehensive service coverage, while less developed systems face the challenges of over-reliance on informal care and high unmet needs.
This report highlights demographic trends and the impact of rising awareness in national and international policies to tackle the challenges related to rising needs in long-term care (LTC) as well as to expectations of citizens to be cared for as long as possible in the community. This involves shedding light on the needs of individuals requiring care, the status, characteristics, and experiences of the workforce – including informal caregivers who play an integral role in addressing care needs – and the various unmet needs and inequalities persisting in the care sector. Due to ongoing digital and ecological transformations it is important to consider imminent and potential consequences of climate change and new technologies in the area of long-term care. Last, but not least, financing and governing long-term care remain either low-priority areas or areas of concern in several countries. However, both should be prioritised and addressed proactively, before they escalate into even greater challenges.
Desk research, exploration of data, literature review, policy analysis
Chapter 1 provides an overview of population ageing in Europe, inluding decreasing fertility rates, migration, changes in household composition and increasing life expectancy. Even if higher age is not automatically linked to declining health, it is to be expected that with rising shares of the older population groups European societies will also be confronted with rising need for long-term care.
This historical progression from acute and communicable diseases to higher shares of persons with chronic diseases and long-term care needs is outlined in Chapter 2. The large majority of European countries have experienced a significant increase of life expectancy over the past decades. However, improved longevity is leading to shifts in the types of conditions affecting the population. Chronic diseases, such as cardiovascular conditions and cancer, are now the leading causes of mortality.
Chapter 3 is dedicated to the reactions of European countries in terms of service provision and other measures to support individuals with chronic illnesses, disabilities, or age-related LTC needs. The facts and figures show not only considerable heterogeneity, but also a general tendency to delimit or reduce places in residential care, although in most countries the pace of expansion in community care has not kept pace with the ever-growing demand.
A key characteristic of LTC provision therefore remains the vital role of informal care as shown and analysed in Chapter 4. On average, 15% of the European population provide unpaid care to an older person. Gender disparities are particularly pronounced, as women often bear the brunt of caregiving responsibilities, which reinforces existing gender inequalities. Facts and figures show that, while Nordic countries are characterised by high percentages of caregivers (even with a relatively equal gender balance), the intensity of care tends to be lower, with over 80% of caregivers providing less than 10 hours of care per week. In contrast, intensive caregiving – defined as providing at least 20 hours of care per week – is more prevalent in Southern and East European countries, where the majority of carers are clearly women as spouses or daughters within family structures.
Chapter 5 provides information on the number and status of LTC workers across Europe, again with large disparities between countries. For instance, while Denmark and other Nordic countries employ almost 12% of their labour force in LTC, East and Southern European countries employ only 1-2% of their workforce in the sector. Generally, the LTC sector has contributed significantly to rising employment, particularly of women. With an employment growth from 6.9 million people in 2008 to 9.4 million in 2023 across the EU, LTC has been among the most thriving economic sectors. Women continue to dominate the LTC workforce that spans a range of roles in both residential and home care settings. Workforce shortages are becoming a pressing issue, with the demand for skilled care workers outpacing supply. The next decades will be marked by an ageing LTC workforce and pressures to train, recruit and retain well-qualified professionals. Addressing these challenges by fostering decent working conditions will be key to ensure both the well-being of workers themselves and better quality of life through person-centred LTC delivery.
It will therefore be crucial to secure adequate funding for the LTC sector, which is underlined in Chapter 6 that outlines the variations in the share of spending on LTC as a percentage of GDP across Europe. Facts and figures show that these variations are due to different welfare policy traditions, “care regimes”, funding systems (e.g., out-of pocket contributions), and attitudes towards public spending. Looking ahead, further investment in LTC will be necessary across all European countries, particularly in prevention and improved coordination between health and LTC systems. This is crucial not only to cover growing needs, but also to stimulate employment, reduce avoidable acute healthcare interventions, address gaps and inequalities, and improve the quality and overall effectiveness of both health and LTC services.
In Chapter 7 facts and figures inform about inequalities in care needs that are strongly correlated to income gradients, with related consequences on the use of care services and corresponding out-of-pocket contributions that are widespread in the area of LTC services. Unmet LTC needs vary depending on the severity of care required, with individuals facing more severe difficulties experiencing higher levels thereof. Among older individuals, notable income-related inequalities in access to healthcare can be found, with higher unmet needs for medical care, medications, and mental health services among lower income groups. These disparities may translate into poorer health outcomes and increased inequalities in care needs in later life.
The intersection of climate change, ageing, and LTC is becoming increasingly relevant and critical as highlighted in Chapter 8. Older adults, particularly those with pre-existing health conditions, are more vulnerable to extreme weather events, natural disasters and environmental pollutants. There are compounded risks faced by women, who experience higher morbidity and are more likely to live alone in old age, making them particularly susceptible to climate-related health challenges and adverse climatic and environmental events. More inclusive policies to mitigate the impact of climate change on ageing populations and improve care systems are needed.
Chapter 9 is dedicated to the intersection of ageing, technology and LTC that is often framed as both a potential solution and a critical factor in addressing challenges in policy and practice. The rapid evolution of digital technologies, such as AI and robotics, has the potential to revolutionise care delivery and offer opportunities to enhance care, improving both the independence and quality of life for older adults – provided the human aspects of care are preserved, the rights of care workers are respected, and inequalities in access to care do not deepen further by introducing a new digital divide. New technologies could improve health management and reduce social isolation, empowering older adults to live more independently. In this shift, the digital literacy of both care workers and care recipients will be key to unlocking the full potential that technology has to offer.