Executive summary

The COVID-19 crisis is hitting the long-term care (LTC) sector very hard, both because of the large numbers of people dependent on care falling ill and because of the added exposure of LTC workers to infections. The pandemic is highlighting LTC’s structural problems in terms of insufficient staffing, poor job quality and insufficient skills, all of which have a toll on quality of care and safety.

The LTC sector suffers from shortages of workers, and this is likely to get worse in the future. In three-quarters of OECD countries, growth in the number of LTC workers has been outpaced by the growth in numbers of elderly people between 2011 and 2016. Demand for care will likely keep going up and put more pressure on the LTC sector. The number of people aged over 80 years will climb from over 57 million in 2016 to over 1.2 billion in 2050 in 37 OECD countries. Keeping the current ratio of five LTC workers for every 100 people aged 65 and older across OECD countries would imply that the number of workers in the sector will need to increase by 13.5 million by 2040.

Low job quality leads workers to leave the elderly care sector

LTC workers are often dissatisfied with pay, working conditions and career prospects, adding to the physical and mental stress of the job. That, in turn, leads to low recruitment and retention and an overall shortage of workers in elderly care.

LTC workers earn much less than those working at hospitals in similar occupations. The median wage for LTC workers across European countries was EUR 9 per hour, compared to EUR 14 per hour for hospital workers in broadly similar occupations. There are also more career promotion prospects in hospitals than in the LTC sector.

Non-standard employment, including part-time and temporary work, is common in the sector. Almost half (45%) of LTC workers in OECD countries work part-time, over twice the share in the economy as a whole. Temporary employment is frequent: almost one in five LTC workers have a temporary contract, compared to just over one in ten in hospitals. Furthermore, jobs are physically and mentally very demanding. For example, half of LTC workers do shift work, which is associated with health risks such as anxiety, burnout and depression.

Insufficient training and skills can pose risks to the quality of care

Personal care workers and those providing routine personal care who are not qualified or certified as nurses, account for 70% of the LTC workforce across the OECD. The vast majority of LTC workers are middle-aged women. One in five are foreign-born.

In more than two-thirds of OECD countries, their tasks go well beyond help with basic activities, such as washing, lifting out of bed, helping with feeding. They are often involved in monitoring health, participating in the implementation of care plans and maintaining health records. However, less than half of the surveyed countries require that personal care workers pass or hold a licence or certification. Low qualifications relative to the tasks required can raise the risk of substandard care, particularly to elderly people with more complex care needs.

Policies to attract workers, retain them, and improve productivity

Attracting more workers

Despite the mounting need for more recruitment into the sector, only half of OECD countries have implemented policies or reforms to boost recruitment since 2011. Most initiatives focussed on incentives to (re)enter the LTC sector or on improving its image.

Supporting LTC training programmes for students or the unemployed can be effective: Japan managed to increase in the number of LTC workers by 20% between 2011 and 2015. Other countries such as Israel, the Netherlands and the United States are providing financial support for such training. Belgium, Portugal and the United Kingdom have also tried to improve the perception of LTC jobs by using public image campaigns. Other policy options include recruiting beyond the traditional pool of women, though only a few countries have tried to attract men, notably Norway and the United Kingdom.

Enhancing retention

Increasing retention rates through better job quality and training is a top policy priority to develop an adequate LTC workforce. Low wages, stress, a heavy workload and onerous working conditions all make it hard to keep people in the LTC sector. The poor record in protecting care workers from COVID-19 is likely to make more people question whether working in the sector is for them. More than half of OECD countries implemented measures to improve working conditions and address retention in the past decade.

Evidence from the United States and France shows that wage increases in LTC are associated with greater recruitment of workers, longer tenure and lower turnover. However, wage increases need to be financed and regulated. Otherwise, wage increases that are not matched by increases in resources lead to increased workload and duties.

Collective bargaining can be used to improve working conditions and wages in the sector. The extent of unionisation levels and social dialogue is uneven across and within countries in the LTC sector, limiting its reach. For example, in Germany and Portugal, the profit sector is not covered by social dialogue. In other countries, such as the Czech Republic and Poland, collective agreements are conducted at the enterprise level.

Beyond wages, promoting a healthier work environment and prevention of work-place accidents and illness can reduce absenteeism, turnover and poor workers health. Few countries report nation-wide programmes in this area. The Netherlands has developed coaching programmes, while Japan has workplace counselling services to promote prevention of accidents and burnout. It is to be expected that, post COVID-19, these issues will need more attention than they have received up to now.

Giving workers more flexibility and control can also boost job satisfaction and reduce turnover. Self-managed teams, such as in the Netherlands, Australia and Japan, have given nurses more autonomy. A few countries such as Denmark and Korea promote training and career options for personal care workers.

Improving productivity and outcomes for the money spent

Better use of technology to assist care workers in their job and improved care coordination across home, institutional and hospital care settings are critical to raise efficiency in the sector, particularly for communicating with, and monitoring, patients, as well as improving data records. Assistive technology such as the use of alarms and sensors, for example, in Estonia, Norway and the Netherlands, remote care such as Helix in Australia, monitoring and self-management solutions such as CanAssist in Canada hold potential to increase productivity, improve working conditions and enhance care quality.

As for co-ordination, one-third of OECD countries have implemented task delegation (transferring responsibility for the performance of an activity while retaining accountability for the outcome) between LTC workers since 2011. For instance, Australia and the United States, trained and supervised care workers to assist nurses with medicine management.

Closer integration and coordination among formal care workers, and with informal carers such as family and friends, is also essential. One third of OECD countries have in place policies to support better co-ordination of services more integrated care across and health and social sectors. In some countries, such as Portugal and the United States, multidisciplinary teams care help co-design and co-decide care plans to support the elderly. Less than half of countries (45%) have implemented policies to strengthen co-ordination of care provided by formal and informal long-term care workers. In Australia, for instance, family carers have access to shared care planning tools.

Finally, very few countries invest in activities that help elderly people age well or recover their autonomy when disabled. Nordic countries have rehabilitation or re-ablement embedded as part of the LTC needs assessment and this approach helps to delay long-term care needs. Japan is putting a stronger emphasis on prevention and healthy ageing. Following the COVID-19 epidemic, countries will likely ask LTC workers to place a stronger emphasis on prevention and safety to reduce infections and injuries.