The urgent need for investment in long-term care in Portugal is clear. According to the 2021 Long-Term Care (LTC) Report, some central aspects of the reality of these services at national level are pointed out, including the forecast increase in the population in need of long-term care due to the continuing demographic ageing and, as such, an increase in public spending. The National Network for Integrated Continuing Care (RNCCI) is seen as a reference organisation, but with challenges in terms of access and affordability. The provision of LTC is embodied in the RNCCI's organisational model - based on unified objectives and methods - which introduced a major reform in the provision of LTC services by the national health system and the social security system, with the aim of promoting quality practices.
The report also highlights that in 2019, public spending on LTC in Portugal stood at 0.4 per cent of GDP, significantly lower than the EU-27 average (1.7 per cent). Over time, Portugal has been identified as one of the 27 EU member states with the highest share of direct out-of-pocket funding for LTC. Portugal is also identified as one of the EU-27 Member States with the highest rates of care provided by informal carers. The situation of informal carers has been neglected until very recently, but the approval of the informal carer statute in 2022 brings hope for an improvement in the situation. Ensuring that the implementation of the statute effectively supports informal carers is, according to the same report, a major challenge to be faced, along with promoting greater access and affordability to more formal long-term care. From the point of view of the formal long-term care workforce, this is estimated at around 17,600. The number of informal carers is estimated at approximately 1.1 million, with women representing the majority of informal workers and, above all, formal carers, most of whom have a low level of education.
The greater role of women in care, the vulnerability of working conditions in this sector, the increase in demand and the scarcity of responses are not just challenges for Portugal, but for Europe. These are also some of the reasons behind the European Commission's presentation of the European Care Strategy in 2022.
The background to the European Care Strategy
In order to frame the Strategy, we need to go back to the European Pillar of Social Rights. The Pillar, proclaimed in 2017 (by Parliament, the Council and the Commission), is the guiding framework for building a strong, fair, inclusive and opportunity-rich social Europe in the 21st century. Of the 20 principles that make up the Pillar, there is one specific to long-term care - principle 18 - which states that everyone has the right to quality, affordable long-term care, in particular home care and neighbourhood services. This guiding framework, which is the Pillar, took shape in 2021 when the Commission presented the Action Plan for the European Pillar of Social Rights. According to the Commission, the Action Plan transforms the principles into concrete actions for the benefit of citizens. It also proposes comprehensive EU targets to be achieved by 2030 (1). It also says that realising the Pillar is a shared responsibility of the EU institutions, national, regional and local authorities, the social partners and civil society. The commitment to fulfilment of the Pillar was further reinforced at the Social Summit in Porto in May 2021.
The Action Plan reads: "Health and long-term care systems have been under considerable pressure during the pandemic, adding to existing challenges such as increased waiting times for healthcare, structural staff shortages and rising health inequalities." He goes on to say that "the resilience of long-term care is also being put to the test. The ageing of society is expected to drive an increase in demand for care services, while the lack of quality standards and gaps in access to quality services, particularly in rural areas, are of great concern in many Member States". The document states that in the face of these challenges, the Commission will: Propose an initiative on long-term care in 2022 to establish a framework for policy reforms to guide the development of sustainable long-term care that ensures better access to quality services for people in need.
In her speech on the State of the Union in 2021, Ursula von der Leyen said: "We have decided to propose a new European strategy for care. So that all men and women can benefit from the best possible care and achieve a good life balance.”
The European Care Strategy
The European Care Strategy would therefore be presented in September 2022 and aims to ensure quality, accessible and affordable care services throughout the European Union and to improve the situation of both care recipients and the people who provide them with care, whether professionally or informally. The strategy is accompanied by two recommendations addressed to the Member States: one on the revision of the Barcelona targets for early childhood education and care; and the other - which is what brings us here today - on access to affordable, high-quality long-term care. Both present policy frameworks for reform and investment at national, regional and local level. Both cover the issues of adequacy, availability and quality of care, as well as the working conditions of carers.
In the case of the draft recommendation on access to long-term care, it aims to improve access to high-quality, affordable long-term care for all people who need it; it concerns all people in need of long-term care and formal and informal carers and applies to long-term care provided in all care settings.
In particular, this proposal for a recommendation
- encourages Member States to strengthen social protection for long-term care and to improve the adequacy, availability and accessibility of long-term care services;
- presents a set of quality principles and quality assurance guidelines, based on the Social Protection Committee's previous work in this area;
- calls for improved working conditions and opportunities for qualification and retraining in the care sector, while highlighting the significant contribution of informal carers and their need for support;
- establishes various principles of good political governance and sustainable funding.
Care concerns everyone. Everyone, at some point in their lives (and even at various times), will provide or receive care. We know that people who are vulnerable to poverty have greater difficulties in accessing services and, at various times, the act of caring also leads to situations of poverty. We also know that the formal care sector deals with precarious situations and low salaries, which makes the sector unattractive and not very resilient. According to the Recommendation, Member States are expected to appoint a national coordinator for long-term care and establish a national action plan with specific measures to implement the Recommendation. This was the motto for EAPN Portugal to organise two webinars on the subject in 2023. One provided an insight into the state of CLD in Portugal and the other was dedicated to the labour force working in the services that provide this care.
The recommendations highlighted by EAPN
From the set of recommendations, we would emphasise the urgency of making the provision of care a priority on the national political agenda. It is necessary to invest in defining long-term structural, preventative (preparing for ageing and retirement) and rehabilitation measures. The national action plan on long-term care must be integrated, i.e. it must be able to mobilise different policy areas beyond the social and health areas. It is essential that this plan is accompanied by a sustainable financial plan, mobilising the structural funds and the national budget for this purpose. One of the aspects much emphasised in both webinars was the change in mentality about ageing and older people themselves. The second meeting even emphasised the need to promote education for ageing, gender equality and the defence of human rights from an early age in schools. Related to this valorisation of ageing and older people is the importance of participation. People need to be at the centre of care and the person-centred approach is one of the relevant principles in the quality of care services. Being person-centred also means establishing spaces for listening to and involving the people who benefit from the services and investing in their empowerment.
In improving services, carers (formal and informal) have not been forgotten. Team training and investment in lifelong learning need to be realised. It is important to invest in human resources management plans and in valuing the careers of these professionals. From the point of view of informal carers, training is central, but despite the approval of the Statute of the Informal Carer, there are still measures to be implemented, which puts the situation of these people on a secondary level at national level. The recommendations also point out that the situation of informal carers is particularly difficult in terms of access to long-term care. On the one hand, the existing criteria for access to this care may be leaving out people who need it but don't meet the criteria, and on the other hand, long-term care is unaffordable for informal carers.
The long-term care scenario in Portugal is still a long way from being ideal and from responding to people's real needs. If, throughout our lives, any one of us may care for or need to be cared for, this scenario is worrying and has serious impacts on the lives of the people who care for and are cared for. The impoverishment of people is one of the consequences of this lack of responses in the area of care and a consequence with serious social, economic and human impacts.
(1) at least 78 per cent of the population aged between 20 and 64 should be in employment by 2030; at least 60 per cent of all adults should participate annually in training by 2030; a reduction of at least 15 million in the number of people at risk of poverty or social exclusion
