There comes a time in many people’s lives when their functional and physical abilities decline. To continue to live an active and fulfilling life, people need help – from family, friends, or from people employed to help.

This book is the result of work undertaken at OECD and the product of truly concerted efforts between the OECD Secretariat, governmental delegates and experts from many OECD countries. Within the OECD Secretariat, two Divisions of the Directorate for Employment, Labour and Social Affairs – the Health Division and the Social Policy Division – collaborated on the project.

In 1950, less than 1% of the global population was aged over 80 years. By 2050, the share of those aged 80 years and over is expected to increase from 4% in 2010 to nearly 10% across OECD countries. This population ageing is being accompanied by family ties becoming looser. The need for community involvement in the care for frail and disabled seniors is growing and will do so ever more rapidly in OECD countries.

With population ageing, no clear signs of a reduction in disability among older people, family ties becoming looser and growing female labour-market participation, it is not surprising that the need for care for frail and disabled seniors is growing.* Growth in older age cohorts is the main driver of increased demand for long-term care across OECD countries. Indeed, policy discussion around long-term care reforms is often framed in the context of pressures arising from ageing societies. The statistics speak for themselves. In 1950, less than 1% of the global population was aged over 80 years. In OECD countries, the share of those aged 80 years and over is expected to increase from 4% in 2010 to nearly 10% in 2050.

Long-term care (LTC) is a growing, but relatively small sector in the economy. People older than 65 years of age, especially those aged over 80 years, have the highest probability of receiving LTC services, while women are the main recipients of services. LTC is a labour intensive sector, which is mostly publicly funded. On average, LTC expenditure accounts for 1.5% of GDP across the OECD. Most care is provided by family carers. The LTC workforce (mostly women working part-time in a majority of countries) is about 1.3% of the total OECD workforce. Over the last ten years, new long-term care programmes have been implemented in a number of countries, including cash-for-care programmes in European countries and the United States, aiming at providing consumers with more choice and control over LTC services. Due to the variety in target groups, governance, provision and workforce, LTC services are often fragmented. The connection with health systems is sometimes poor. The size, benefits, target groups, use, provision, governance and financing of long-term care differ markedly across countries. This chapter provides an overview of the sector in OECD countries. It begins by defining long-term care. In the following sections, it offers a snapshot of who uses, provides, and pays for long-term care services. Another section describes available services, with a focus on cash-for-care programmes, while the final section offers a short overview of recent policy developments in the sector.

Pressures on long-term care (LTC) systems are expected to grow in the future, for at least four reasons. First, although the speed at which populations are ageing varies considerably across countries, and despite uncertainties about future trends in disability among the population, demographic transformations will increase demand for LTC services in all societies. Second, changing societal models – such as declining family size, changes in residential patterns of people with disabilities and rising female participation in the formal labour market – are likely to contribute to a decline in the availability of family carers, leading to an increase in the need for paid care. Third, as societies become wealthier, individuals demand better quality and more responsive social-care systems. People want care systems that are patient-oriented and that can supply well co-ordinated care services. Fourth, technological change enhances possibilities for long-term care services at home but may require a different organisation of care. These factors will create upward pressure on the demand for long-term care services. They will raise pressure for improving the provision of care services and their performance, and, therefore, their cost. This chapter presents demographic forecasts for OECD countries, and projections on family carers in selected OECD countries and long-term care costs.

Supporting the role of informal carers (family and friends providing mostly unpaid care to frail seniors) is important to provide an adequate continuum of care between informal and formal care. While caregiving can be beneficial for carers in terms of their self-esteem, it can be difficult for working-age carers to combine paid work with caring duties and carers may choose to quit paid works or reduce the work hours. This may compromise their future employability and lead to permanent drop-out from the labour market. Caring may also cause burnout and stress, potentially leading to worsening physical and mental health. This chapter offers an overview of the characteristics of family carers and the impact of caring for frail seniors on labour market and health outcomes of carers. This will provide insights in how to shape policy reforms with the objectives of 1) helping carers to combine caring responsibilities with paid work; and 2) improving carers’ physical and mental wellbeing by reducing mental health problems. Countries which want to maintain or increase reliance on family carers will need to alleviate the burden of family carers and reduce the economic costs associated with caring responsibilities.

In most countries, family carers and friends supply the bulk of caring, and the estimated economic value exceeds by far expenditure on formal care. A continuation of caring roles will be essential given future demographic and cost pressures facing long-term care (LTC) systems across the OECD. This is also what care recipients themselves prefer. Continuing to seek ways to support and maintain the supply of family care appears therefore a potentially win-win-win approach: For the care recipient; for the carers; and for public systems. This chapter provides an overview and an assessment of the current set of policies targeted to family carers, in relation to three main aspects: Caring and the labour market, carers’ wellbeing, and financial recognition to carers. The effectiveness of policies in helping carers combine care with paid work, in reducing burnout and stress of carers, and in recognising the additional costs associated with caring will then be discussed.

This chapter describes the size and the composition of the long-term care (LTC) workforce, in terms of gender and skill mix, working hours and work pressures. The analysis focuses on the two major parts of the LTC workforce: those working in home care and those working in institutional care. Developments in the mix of qualifications in nursing LTC are considered. The chapter then examines the relative importance of factors behind the difficulties in matching demand for, with the supply of, LTC workers, such as salary levels and working conditions. The analysis seeks to answer the following questions: does the workforce meet current (and potential) demand? How many people work in the different components of LTC sector and what is their background? What are the working conditions in the LTC sector? What can be said about developments over time?

Although the effects of the economic crisis may mitigate shortages of LTC workers in the near future, an integrated approach is required to prepare for the LTC workforce in the longer term. Measures can be targeted at education, recruitment and retention, as well as at job content, productivity and quality. These can cover subsectors (home care, day care, residential care) but could also take the form of integrated sector approaches. Furthermore, for different categories of workers (nurses, lower-level workers), specific policies may be required, as for nurses an LTC career often is not a natural choice, while for lower-level workers LTC jobs are often not perceived as a “profession” but as “dead end job”, with few options for progressing other than finding a job elsewhere. This can lead to high turnover and limited job retention, with subsequent high cost for employers, public finances, those in need of care and their families. Potential measures look at valuing LTC work and the workforce and may require substantial change in the organisation and management of care. Moreover, while in some countries foreign-born workers will represent sizable shares of the LTC workforce, there may be questions about the sustainability of such an approach. This chapter explores policies to improve inflows, retention, and productivity of LTC workers.

With population ageing and reductions in family care, utilisation of formal long-term care for disabled people is growing in all high-income countries. Higher demand for formal services is emerging also because of people’s expectations for high-quality care. These factors are pushing up the cost of formal long-term care across OECD countries and raise questions about who should pay more prominent in policy discussions. This chapter offers an overview of public long-term care (LTC) coverage in OECD countries. For illustrative purposes, countries are clustered into three main groups, ranging from universal and comprehensive to means-tested system or systems with a mix. Over time, coverage systems are evolving towards universal systems or benefits and more user-choice models, with, in many cases, increased targeting of care benefits to those with the highest care needs.

Given the expected increase in total long-term care (LTC) expenditure, there is interest in some OECD countries in the potential role of private LTC insurance. Indeed, financial planning for retirement may include the subscription to a private LTC coverage product to protect one’s income and assets against the risk of needing long-term care, in order to reduce the burden it would create on the family and provide more choices regarding the care received. But, there are very different views regarding the merit of private LTC coverage. For some, this could leverage new financial resources towards long-term care, thereby alleviating future potential pressures for governments to increase their support. For others, it could represent a less efficient and more costly way to ensure universal and comprehensive coverage, relative to public pooling. However, private long-term care coverage arrangements represent small markets in OECD countries. This chapter describes and analyses the role and size of private LTC coverage arrangements across OECD countries. It examines the potential factors affecting the size of LTC insurance markets and countries’ initiatives to encourage its development. It then discusses the role that private insurance arrangements could play in LTC systems in the future.

For most individuals, it is difficult to foresee whether long-term care (LTC) will be required in the future, and if so, the type, the duration and the cost of that care. Over the next decades, public expenditure in most OECD countries is expected to grow rapidly, in most part because of the expected increase in age-related expenditure, such as public pension, health and LTC services. Generally, given current tax mixes and levels, expected revenues are set to grow at a slower rate than expenditures, with the potential risk of shifting their cost to future generations. The policy challenge can thus be framed as providing fair protection against the financial risk associated with long-term care, while ensuring that the way LTC revenues and expenditures is sustainable in the long-run. Targeted universalism and a forwardlooking set of collective financing policies have the potential to help striking a reasonable balance between these two competing priorities. This is what this chapter will examine.

It is well established that ageing populations will lead to increases in the demand for services in the years to come, thereby putting upward pressure on total expenditure on formal long-term care (LTC) systems in a context where large spending items such as pensions and health are also expected to grow. This may well create pressure on governments to ensure that spending in the sector is well worth the expenditure, or, in other words, that systems of long-term care deliver value for money. A review of OECD countries’ experiences reveals different policies aimed at improving the efficiency of LTC systems and the “interface” between LTC and health care. However, it is evident that this is an area for further work: often, no definite conclusions can be drawn.