The following article is a summarized extract from the World Health Organization’s 2008 publication “Home Care in Europe: The Solid Facts”, designed to explain why health and social services should provide high-quality and targeted home care for disabled and older people while exploring the varied cultural and care contexts across different countries.

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Many factors drive the need and demand for home care: demographic trends, changes in the epidemiological landscape of disease, the increased focus on user-centred services, the availability of new support technologies and the pressing need to reconfigure health systems to improve continuity, responsiveness, efficiency and equity.

Home care is understood and practised differently around the European Region. Similarly, the evidence about the appropriateness and effectiveness of home care is complex and diverse and hence poses an inherent challenge to gather and to analyse and make informed decisions.

an overview

Home care aims at satisfying people’s health and social needs while in their home by providing appropriate and high-quality home-based health care and social services, by formal and informal caregivers, with the use of technology when appropriate, within a balanced and affordable continuum of care.

Life expectancy has risen sharply in the WHO European Region in the last few decades. The proportion of older people in the general population is increasing steadily in many European countries and is predicted to rise still further in the coming decades. This will mean increasing rates of care-dependent older people. The next decades will also see dramatic changes in the needs of those with non-communicable diseases, as the leading cause of disability and death. A variety of people with chronic conditions may stay at home given difficulty in mobility, and dependent children with severe health problems or people with mental disorders may also require home care.

Sociodemographic change and mobility trends affect home care needs. The break-up of the traditional large family group and other sociological trends, such as urbanization, complicate the situation. Family groups are often intact in rural areas, with many generations living in a household and family members taking care of the older or disabled family members. Urban communities are different, with small family units, limited living space and the younger generations often moving away from their families because of work commitments. All these factors increase the likelihood of today’s and future generations needing additional care that their relatives are unlikely to provide and place a major responsibility on all levels of government: national, regional or district and especially municipal, where home care is applied in practice.

These changes in needs and social structure require a different approach to health and social sector policy and services, since a disease oriented approach alone is no longer appropriate. Evidence suggests that disabled and older people tend not to want institutional care, and families and other informal carers prefer strongly to continue to care for their dependent family members in a friendly environment such as their own homes and local communities.

In the present and in the future, decision-makers would envision home care as a sustainable approach to prevent the need for unnecessary acute and/or long-term institutionalization and maintain individuals in their home and community as long as possible.

an emerging need

Although the particular history, drivers of change and subsequent policy responses vary across Europe, all countries are similarly facing a set of common demographic, social, technological, epidemiological and political pressures that influence both the demand and supply of home care demand and provision.

Influences on the supply and demand for home care

demographic shifts

Demographic changes are leading to an increased demand for home care. The population structure within European Union (EU) countries is set to change dramatically in the near future. In particular, the proportion of old and very old people is set to increase, while the number and relative proportion of children, young people, young adults and adults will decline, as fertility rates are falling sharply.

Although the rates vary by country, they are set to fall further, resulting in an ageing population profile and reducing the dependency ratio of carers to dependents. This will affect the tax base for funding public services and the available pool of formal and informal carers.

The demand for home care is known to increase with age, even if individuals become dependent at a later stage than previous generations; the latter is due, for example, to improvements in lifestyle, food, personal hygiene and housing. Improvements in disease prevention, standards of living and self-care activities will also influence the level of assistance required and overall levels of dependence.

social change

Changes in social attitudes, values and behaviour contribute to increasing the demand for formal home care services. The fragmentation of the traditional large family group into small family units in an urbanized context reduces the number of people who can provide care to dependent family members. In addition, female labour market participation has risen steadily, and greater emphasis is placed on facilitating paid work and enhancing career opportunities for women. Increased female labour market participation and tighter regulation of labour markets results in the availability of a smaller pool of family care. In countries where labour market incentives and active labour market policies seek to raise the participation of women further, this has serious implications for the provision of both informal and formal care. These policies are part of the much broader Lisbon strategy for growth and employment of the EU that addresses measures to delay retirement and discourage early retirement to increase labour market participation among all sectors of the European population. Thus, since the peak age of the people caring for an older person is between 45 and 60 years, these would result in a global shortage of informal carers.

Greater internal mobility across Europe at all points in the life course (working and retirement age) can give rise to considerable distances between family members. In countries recently joining the EU, younger and professional groups have migrated significantly, contributing to not only brain drain but also potentially a widening care gap

changes in epidemiology

Improvements in public health have contributed towards changing epidemiology. A rise in non-communicable diseases influences the demand for home care, including the following:

• Mental illness is being increasingly recognized and treated, and community care is preferred to institutionally based care.
• The pattern of disease is changing. Some diseases such as Alzheimer’s disease and dementia are becoming more prevalent in an ageing population. There is also greater awareness and understanding of such conditions and how effective treatments and support may be offered within a home setting by using a range of home care services.
  
• More people are living with the consequences of diabetes, heart diseases, respiratory diseases, stroke and cancer: these could be effectively and efficiently taken care of at home with appropriate and targeted support.

science and technical innovation

Developments in science and technology (both medical and non-medical) are affecting the demand for and the supply of home care. Medical advances including pharmaceuticals, devices and surgical technologies have contributed towards increasing life expectancy and enhancing the quality of life for many disabled people, older people and children with complex care needs. Simple home modifications (such as adapted toilets, showers and baths and lifting equipment) more easily match residential settings to the needs of people with impairment. The development of technology and innovation promises to deliver a range of opportunities and solutions for population groups wishing to remain in their home, and both high- and low-technology home care solutions are supplementing and complementing traditional home care services.

changes in attitudes and expectations

There are rising expectations around consumer choice and citizen voice within the organization and delivery of services.

• In some settings, such as for home care, a discourse of entitlement or user rights has grown up around the importance of individualized and customized care and has emphasized the importance of user choice, control and self-determination in the funding and provision of services.
  
• The appropriateness of institutional provision is increasingly questioned, and home- and community-based solutions and services are preferred. Almost 90% of respondents in one European survey felt that social and health care systems should help older people to remain in their homes for as long as possible.
• With increased population mobility and migration, all European countries have to address the needs of diverse populations. The public expects services to be culturally sensitive and to better reflect the needs of ethnic minority groups, which in turn generates new demands for home care provision.

policy priorities and choices

A range of policy changes and priorities create pressure on home care. There is policy support for the idea that home-based solutions benefit individual users, their families and society more broadly.

• In most European countries, deinstitutionalization and community living are accepted as general principles underpinning the formulation of policy, including:
  (1) closing long-stay mental institutions,
  (2) individuals with learning disabilities living in community and small-scale settings and
  (3) older people experiencing better quality of life under community care rather than long-stay nursing and residential homes.
• There are concerns about the pressure on public expenditure associated with the ageing population, particularly around pensions and health care costs. Health spending grew faster than gross domestic product in virtually all countries in the Organisation for Economic Cooperation and Development (OECD) from 1990 to 2004.
• Home-based solutions are advanced not only for health, social and emotional benefits but also because of the potential reduction in public expenditure, as home care provision has been demonstrated to be more effective and efficient than institutionalized care.
• Primary care (such as home-based nursing services, hospital and hospice-at-home care) is seen as central in ensuring the quality of life, and this has been coupled with a shift of resources from acute and long-stay beds to community care within the health and social service systems.
• Recognition of the pivotal role of informal care (both family and friends or neighbours) in contributing towards providing care has led to increased demands for policy and service providers to recognize and sustain these fundamental actors.