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Long Term Care in Europe: An Introduction

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Abstract

Long Term Care (LTC) has started to become an issue in modern social protection. It means support for those who are not able to independently perform activities of daily living (ADLs). Whereas this support has, even after the introduction of social security in most developed states during the first half of the last century, remained mainly a task of families and social institutions for a long time, more and more states have, over the past decades, started to introduce social benefits for those dependent on care. This is, first, due to the fact that the situation of many persons in need for support calls for professional assistance. Second, there are fewer and fewer persons who might be able to provide non-professional care, such as relatives and neighbours, and fewer reliable social networks are formed that would suffice in order to cover the social needs of dependent persons. The most relevant factor for the growing involvement of public authorities is, third, the demographic development. The populations of most developed states are growing older than ever due to a rising life expectancy. This is a well-known and widely acknowledged development which does not need further explanation at this point. It may, on the one hand, be regarded as good news as it leads to an expansion of our life spans. Yet, medical evidence seems to back the assumption that the growing life expectancy also has, on the other hand, a negative side. Gerontologists tend to differentiate between ‘younger’ and ‘older’ elderlies. Wherever the borderline actually has to be drawn, ‘older elderlies’ run a relatively high risk of becoming dependent on support, and this risk seems to increase with biological age. Taking into account population ageing, it is most presumable that our future societies will consist of a higher percentage of dependent persons than today. A second demographic process has to be taken into account. In many developed countries, the fertility rate is below what demographers call the reproductivity rate. Of course, there are considerable differences between the Member States of the European Union in this respect. But those with a low fertility rate will encounter the problem that the number of persons prepared to provide non-professional care will consistently decrease. At least, more efforts have to be taken in order to stabilise the respective basis for non-professional LTC—which is already weakened as changes in society and labour market participation affect both the attitude towards non-professional care as well as the capacities for making time for such caregiving.

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Notes

  1. 1.

    See below, Sect. 2.1.

  2. 2.

    The average life expectancy in the EU increased from 77.9 years in 2005 to 80.9 years in 2014. Spain is at the top with a life expectancy of 83.3 years, while Latvia occupies last place with merely 74.5 years. Life expectancy strongly varies between women and men. In 2014, it was for women 83.6 years and for men 78.1 years in the EU which is an increase for both sexes compared to 2005 when it was 80.9 years for woman and 74.8 years for men (http://ec.europa.eu/eurostat/de/data/database).

  3. 3.

    See Baltes and Smith (2003), pp. 123 et seq. Whether or not this will lead to a decrease in disability rates for the young old is disputed, see Jagger et al. (2011), pp. 7 et seq.

  4. 4.

    This rate of 2.1 children per woman remains unachieved in Europe. The average fertility rate of the European Union adds up to 1.5 children per woman. The country with the highest fertility rate is France with 1.96, the country with the lowest rate is Portugal with 1.31 children per woman (http://ec.europa.eu/eurostat/de/data/database).

  5. 5.

    And the policy reactions are different; see for a legal comparison Becker et al. (2014).

  6. 6.

    See the chapter by T. Dijkhoff, this volume.

  7. 7.

    See Lipszyc et al. (2012).

  8. 8.

    E.g. Katz (1983), pp. 721 et seq. The debate has also led to more differentiation, especially with the introduction of the term ‘Instrumental ADL’ (IADL), and it has emphasized the important role of measurement, e.g. Wiener et al. (1990), pp. 229 et seq.

  9. 9.

    As laid down in Art. 1 to 3 of the EU Charter of Fundamental Rights (CFR).

  10. 10.

    No. R (98) 9 (https://wcd.coe.int/com.instranet.InstraServlet?command=com.instranet.CmdBlobGet&InstranetImage=532369&SecMode=1&DocId=486242&Usage=2).

  11. 11.

    Which might be appropriate as the relevance of functional deficits very much depends on social environment and cultural background.

  12. 12.

    Which serves as a WHO framework for measuring health and disability at both individual and population levels and has replaced the previous International Classification of Impairments, Disabilities and Handicaps (ICIDH); ICF is available at: http://www.who.int/classifications/icf/en/.

  13. 13.

    Available at: http://www.un.org/disabilities/documents/convention/convoptprot-e.pdf.

  14. 14.

    See Council Decision of 26/11/2009, OJ L 2010/23, p. 35.

  15. 15.

    Available at: http://www.ilo.org/dyn/normlex/en/f?p=NORMLEXPUB:12100:0::NO:12100:P12100_INSTRUMENT_ID:312247:NO.

  16. 16.

    Now based on Art. 48 of the Treaty on the Functioning of the European Union (TFEU).

  17. 17.

    Regulations No. 3 and 4 of 1958.

  18. 18.

    See also Regulation No. 1408/71 on the application of social security schemes to employed persons, to self-employed persons and to members of their families moving within the Community (OJ L 149/1971, p. 2).

  19. 19.

    OJ L 166/2004, p. 1.

  20. 20.

    See also Schulte (2013), pp. 207, 213.

  21. 21.

    ECJ of 5/3/1998, C-160/96 (Molenaar), par. 22 et seq.: ‘With regard to the second condition, it appears from the file that care insurance benefits are designed to develop the independence of persons reliant on care, in particular from the financial point of view. The system introduced is aimed at encouraging prevention and rehabilitation in preference to care and at promoting home care in preference to care provided in hospital. Care insurance gives entitlement to full or partial direct payment of certain expenditure entailed by the insured person’s reliance on care such as care provided in the home, in specialised centres or hospitals, the purchase of equipment required by insured persons, the carrying out of work in the home and the payment of monthly financial aid allowing the insured to choose the method of assistance they prefer and, for example, to remunerate in one form or another the third party assisting them. The care insurance scheme provides cover, furthermore, against the risks of accident, old age and invalidity for some of those third parties. Accordingly, benefits of that type are essentially intended to supplement sickness insurance benefits to which they are, moreover, linked at the organisational level, in order to improve the state of health and the quality of life of persons reliant on care. In those circumstances, even if they have their own characteristics, such benefits must be regarded as ‘sickness benefits’ within the meaning of Article 4(1)(a) of Regulation No 1408/71.’

  22. 22.

    See ECJ of 5/3/1998, C-160/96 (Molenaar), par. 20: “The Court has consistently stated that a benefit may be regarded as a social security benefit in so far as it is granted, without any individual and discretionary assessment of personal needs, to recipients on the basis of a legally defined position and provided that it concerns one of the risks expressly listed in Article 4(1) of Regulation No 1408/71”. See also ECJ of 10/10/1996, C-245/94 and C-312/94 (Hoever and Zachow), par. 18.

  23. 23.

    See for the German-Turkish Social Security Agreement of 1964 (revised in 1984) the judgement of the German Federal Social Court of 25/2/2015, B 3 P 6/13 R.

  24. 24.

    See above, Sect. 2.2.

  25. 25.

    See above, Sect. 2.2 and footnote 22.

  26. 26.

    See for example General Comment No. 19 of the Committee on Economic, Social and Cultural Rights on the Right to Social Security, http://tbinternet.ohchr.org/_layouts/treatybodyexternal/Download.aspx?symbolno=E%2fC.12%2fGC%2f19&Lang=en. See also Becker and Pennings (2013), pp. 1, 3.

  27. 27.

    See Zacher (1989), col. 59 et seq.

  28. 28.

    See most recently ‘Annual Growth Survey 2016 Strengthening the recovery and fostering convergence’, COM(2015) 690 fin.

  29. 29.

    See Mutual Information System on Social Protection (http://www.missoc.org/MISSOC/index.htm).

  30. 30.

    See the definition on the website of the EU Commission: ‘Social protection systems are designed to provide protection against the risks and needs associated with: unemployment, parental responsibilities, sickness and healthcare, invalidity, loss of a spouse or parent, old age, housing, and social exclusion’ (http://ec.europa.eu/social/main.jsp?catId=1063&langId=en).

  31. 31.

    See for example ‘Europe 2020: A strategy for smart, sustainable and inclusive growth’, COM(2010) 2020 fin.; also on the website of the EU Commission: ‘Social Protection & Social Inclusion’ (http://ec.europa.eu/social/main.jsp?catId=750).

  32. 32.

    See already Becker (2010a), pp. 1, 14 et seq.

  33. 33.

    Cf. Allison (2004).

  34. 34.

    See also below, Sect. 4.1.

  35. 35.

    Esping-Andersen (1990). Although Esping-Andersen himself has brought about more differentiation in the meantime, it still serves as a starting point for comparisons in social policy research. See for a categorisation of European countries also Obinger et al. (2005), pp. 1, 23 et seq.

  36. 36.

    See for example David and Jauffret-Spinosi (2002). For other approaches for the categorisation of jurisdictions and their significance in the context of social protection Becker (2014), pp. 463, 479 et seq.

  37. 37.

    See, for the mixed health systems in Central and Eastern European countries Leienbach (2000), pp. 49, 52, 56; Pitschas (2000), pp. 323, 333, 336.

  38. 38.

    Which also holds true for the mode of financing. The British NHS is partly financed from contributions, whereas the French statutory health insurance receives money from a type of contribution which is very similar to taxes (contribution social généralisée).

  39. 39.

    See Zacher (1987), pp. 571 et seq.; Becker (2010c), pp. 607 et seq.; for a different way of structuring this field see Harris (2000), pp. 155 et seq.

  40. 40.

    See above, Sect. 3.1.

  41. 41.

    See for example Art. 38 par. 2 (previdenza) und Art. 38 par. 1 (assistenza) of the Italian constitution. For a similar distinction in Portugal Vergho (2010), pp. 47 et seq.

  42. 42.

    Even if not in the sense of the stricter principle of equivalency followed in private insurance law.

  43. 43.

    Both the selective character and the differentiated level of protection hold true for the Bismarckian type of social insurance, whereas the Beveridgean type aims at ensuring a universal basic coverage, based on flat-rate contributions and benefits.

  44. 44.

    See for the different objectives of respective benefits and different arguments for the establishment of a ‘public responsibility’ Becker and Körtek (2010/2011), pp. 169, 171 et seq.

  45. 45.

    Pflege-Versicherungsgesetz of 26/5/1994 (BGBl. I pp. 1014, 2797).

  46. 46.

    With a differentiation between ambulatory and stationary benefits.

  47. 47.

    See the chapter by H.-J. Reinhard, this volume, for more details.

  48. 48.

    See for the development in Japan and Germany Matsumoto (2007), pp. 59 et seq.

  49. 49.

    See Sunwoo (2012), pp. 49 et seq.

  50. 50.

    Zweites Pflegestärkungsgesetz of 21/12/2015 (BGBl. I, p. 2424).

  51. 51.

    See above, Sect. 2.1.

  52. 52.

    See above, Sect. 3.1.

  53. 53.

    Example for a misled view: COM(2006) 117 fin., p. 5: ‘general aspects of this modernisation process can be seen […] the outsourcing of public sector tasks to the private sector, with the public authorities becoming regulators, guardians of regulated competition and effective organisation at national, local or regional level’.

  54. 54.

    For a detailed analysis Becker et al. (2011).

  55. 55.

    On the background of the disputable, but standing jurisprudence according to which social activities have a different quality compared to economic ones, see first ECJ of 17/2/1993 Case C-159/91 and C-160/91 Poucet and Pistre [1993] ECR I-637; most recently ECJ of 5/3/2009, Case C-350/07 Kattner [2009] ECR I-1513.

  56. 56.

    ECJ of 11/7/2006, Case C-205/03 Fenin [2006] ECR I-6295, par. 26. See for an analysis Krajewski and Farley, ELRev. 32 (2007), pp. 111 et seq.

  57. 57.

    For details concerning the situation in Germany see Becker et al. (2011), pp. 323 et seq., (2012), pp. 1 et seq. and 103 et seq.

  58. 58.

    See for a detailed analysis of the use of legal instruments to the abovementioned ends Landauer, 2012, pp. 136 et seq.

  59. 59.

    See Becker et al. (2011, 2012).

  60. 60.

    Including the EU Charter of Fundamental Rights (CFR) as a general legal text on commonly acknowledged fundamental rights in the EU; in particular Art. 1 (human dignity), Art. 2 and 3 (right to life and to integrity), Art. 7 (respect for private and family life), Art. 26 (integration of persons with disabilities), and in a positive dimension, but very openly put, Art. 34 par. 1: ‘The Union recognises and respects the entitlement to social security benefits and social services providing protection in cases such as maternity, illness, industrial accidents, dependency or old age, and in the case of loss of employment, in accordance with the rules laid down by Community law and national laws and practices’.

  61. 61.

    See Council of Europe, R (89) 9 (fn. 10).

  62. 62.

    See for an overview Becker and Lauerer (2011), pp. 121, 133 et seq.

  63. 63.

    See Urban (2016).

  64. 64.

    As it is the case in Japan for example.

  65. 65.

    See for Germany Becker and Lauerer (2011), pp. 121, 138 et seq.

  66. 66.

    See Council Decision of 5/10/2015 on guidelines for the employment policies of the Member States for 2015 (OJ L 268/2015, p. 28), Guideline 6: ‘Enhancing labour supply, skills and competences’, including the following paragraph: ‘Female participation in the labour market should be increased and gender equality must be ensured, including through equal pay. The reconciliation between work and family life should be promoted, in particular access to affordable quality early childhood education, care services and long-term care.’

  67. 67.

    See also Scheil-Adlung and Bonan (2013), pp. 25 et seq.

  68. 68.

    See Laferrère and Van den Bosch (2015), pp. 331 et seq.

  69. 69.

    See also for an overview on existing national legislation in the EU: Mutual Information System on Social Protection, Comparative Tables, XII (http://www.missoc.org/MISSOC/INFORMATIONBASE/COMPARATIVETABLES/MISSOCDATABASE/comparativeTableSearch.jsp).

  70. 70.

    OECD (2011). See also the articles in Eurohealth (2011), no. 2–3.

  71. 71.

    OECD (2013).

  72. 72.

    Costa-Font (2011) and Leichesenring et al. (2013).

  73. 73.

    See for the UN Convention on the Rights of Persons with Disabilities above, Sect. 2.1; for the constitutional background and the EU CFR above, Sect. 4.1.

  74. 74.

    See for economic aspects Costa-Font and Courbage (2012); De La Maisonneuve and Martins (2013).

  75. 75.

    See for outside Europe WHO (2003).

  76. 76.

    See for Southern Europe Da Roit et al. (2013), No. 4, pp. 577 et seq.

  77. 77.

    See above, Sect. 3.2.

  78. 78.

    See for the very restricted meaning of these models above, Sect. 3.2.

  79. 79.

    The current debates on the comparative method, which continues to focus on the principle of functionality, essentially deal with two different issues: for one thing, they deal with epistemological requirements which mainly regard the finding of the subject that forms the basis of a comparison, i.e. which regard the locating of the relevant law. For another thing, they deal with the function and the functioning of the law and, in doing so, address the objectives of the comparison of laws, Becker (2010b), pp. 11, 20 et seq.

  80. 80.

    Zweigert and Kötz (1998), p. 35. For the relevance in social law research Pieters (1998), pp. 715, 726 et seq.

  81. 81.

    See Esser (1972), pp. 97, 103 et seq., 110 et seq.

  82. 82.

    See above, Sect. 3.2.

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    Ulrich Becker

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    Ulrich Becker

  2. Fulda University of Applied Sciences, Fulda, Germany

    Hans-Joachim Reinhard

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Becker, U. (2018). Long Term Care in Europe: An Introduction. In: Becker, U., Reinhard, HJ. (eds) Long-Term Care in Europe. Springer, Cham. https://doi.org/10.1007/978-3-319-70081-6_1

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