Foreword

Elderly people and their care workers have been disproportionately affected by the COVID-19 pandemic. Older adults and those with multiple chronic conditions or health risk factors are at a significantly higher risk of severe complications from the disease than other groups, and indeed most of the deaths have been among the elderly. Across the OECD, more than one in six people are older than 65, with 60% of them living with multiple chronic conditions. In addition to the added health risks, certain elderly people significantly struggle to access social support, or to cope with the mental strains provoked by the COVID-19 crisis.

Many OECD countries have taken measures to contain the spread of the infection and mitigate its impact on vulnerable groups. Yet the health crisis is highlighting and exacerbating pre-existing structural problems in the long-term care (LTC) sector. In many OECD countries, recruiting enough workers in LTC remains a challenge and care workers experience difficult working conditions. Skills mismatch, poor integration with the rest of health care and inadequate or poorly enforced safety standards in LTC lie at the root of preventable hospital admissions even in normal times. During a pandemic, the structural shortcomings in the LTC sector are becoming even more visible: care workers are under huge strain in delivering their services in often very difficult conditions and limited support. This in turn is affecting the management of the infection and exposing elderly people to further risks.

Looking forward, the evident challenges in the LTC sector are likely to become ever more acute if no further action is taken to address these structural shortcomings. Demand for LTC is expected to grow in the coming decades, with the proportion of the population over 80 years-old projected to double by 2050 in the OECD. Also by 2050, there will be only two persons of working age for every one person over 65 years old. This large increase in the old-age dependency ratio can constrain the supply of both informal and formal long-term care workers (LTC). In short, demand for care is going up, the supply pool is dwindling. As more people live a longer life, complex health and care needs and multiple comorbidities are becoming more common, particularly among the oldest old. As no two elderly have the same needs, LTC systems need to move towards a model of care that is more tailored, person-centred and better integrated with the rest of health care.

This new report provides a detailed picture of LTC workers: 90% are women, over 20% are foreign-born and over 70% of LTC workers are personal carers with low entry requirements into the job, with 56% of workers being in institutions and the rest working in individual homes. The report highlights the main functions and tasks of LTC workers and finds that care is often more complex than generally portrayed and that LTC workers are often not well-equipped with the right skills. In more than two-thirds of countries, personal care workers’ tasks go well beyond activity of daily living provision (i.e. help with dressing or hygiene) and involve cooperation with other professionals. In more than three-quarters of countries, nurses working in the LTC sector perform case management tasks, and they lack sufficient geriatric and interpersonal skills training. Most workers do not stay long in a LTC sector that is characterised by a high labour turnover because of poor working conditions. Pay is 35% lower than the hospital sector for workers in the same occupation; the rate of part-time work is often twice as high as in the overall labour force and more than 60% of workers are exposed to physical risk factors.

This report examines different recruitment policies across countries, in particular those focusing on unemployed people and on improving the image of LTC. It finds that only half of the countries have implemented recruitment policies or reforms since 2011. In evaluating country progress, this report draws attention to the importance of policies to improve working conditions, especially providing better wages, improving workers’ autonomy, and addressing occupational health challenges. The report also highlights the role of social dialogue in achieving such policy changes. Task delegation can help to address some skills mismatches and increase efficiency, as long as workers are adequately trained. Leveraging productivity gains through appropriate use of technology, for example by promoting the use of sensors and alarms and facilitating the sharing of information electronically, will help LTC workers to focus more on personal attention to the elderly. Enhancing prevention and ensuring that the elderly stay healthy and independent for as long as possible will also help to ensure that they can stay safely at home if they wish to. This can be done, for example by improving the collaboration between LTC workers and other health professionals such as GPs and those in hospital care and improving the expertise of LTC workers to detect health risks and manage health conditions.