Germany

Demographic information (Statistisches Bundesamt, 2009)

• Inhabitants: 81,802,300
• No. of citizens 65+: 16,901,700
• No. of citizens 75+: 7,281,309
• No. of people with long-term care needs (according to national eligibility criteria): about 2.34 million

Characteristics of health, social and long-term care delivery

Long-term care in Germany has an established financial and delivery base. The long-term care insurance was implemented in 1996, and an  increasing number of long-term care providers for home care as well as care homes have been established since that date. The statutory long-term care insurance scheme is organized in a similar manner to other social insurance systems in Germany (pension, employment and health insurance). It is institutionally linked to the social health insurance and compulsory for all employees below a certain income. However, the long-term care insurance is limited in scope with regard to actual care needs and is understood to be complementary (partial coverage). It guarantees a basic coverage of care needs, with three levels of care subject to assessment by the Medical Review Board, to which all older people have access in principle. This leads to coverage by the social health and long-term care insurance of about 99.7% of the German population (Gesundheitsberichterstattung des Bundes/Statistisches Bundesamt).

Long-term care delivery funded by the LTC insurance includes the services of the long-term care system itself and additional services offered by the health and social care systems. However, according to estimates from 2007, approx. three quarters of all hours of care for older people are provided by informal carers.

Two simplified illustrations of LTC provision in Germany

• Download here an illustration of possible LTC pathways for Mrs. L.T. Care in Germany. 
• Download here an illustration of possible LTC pathways for Mr. L.T. Care suffering from dementia in Germany.

Background information on key-issues

Prevention and rehabilitation in LTC

Ideas for ‘upstream’ approaches in LTC aimed at keeping older people healthier and more independent for longer, have gained attention in current German LTC policy debates. The main goal of LTC insurance, to prevent residential care as long as possible and facilitate life in private homes (“home care instead of residential care”), can be understood as a preventive approach. In addition, nursing concepts such as ‘activating care’, with positive effects in terms of prevention and rehabilitation, are now widely recognised as state of the art. Against the backdrop of a solidly developed foundation (basic coverage of needs by long term care insurance, general access) the existing preventive and rehabilitative potential in the field of seniors’ health still needs to be developed. Current/future challenges include e.g. to target specific services for client groups of older people with specific needs (diversity aspects); to transfer the knowledge generated from the multiplicity of local good practice pilots in order to shape  mainstream services; to implement new incentives for cooperation and the development of integrated care pathways; to promote innovative and client-centered approaches in mainstream services; to further discourage paternalistic and de-activating approaches and to prevent the negative impact of scarce resources on qualification of staff and time available for care (more …)

The role of informal care in LTC

In Germany informal care – generally provided on an unpaid basis by family members, friends, acquaintances and neighbours – is of great importance. In 2005, approx. 66.7 million hours per week were provided by informal carers out of a total of about 88.5 million hours of weekly care provision. This situation accords with significant political maxims:

• People in need of care should, as far as is reasonable and feasible, be cared for at home (motto: “home care rather than institutional care”).
• Home care should, as far as is reasonable and feasible, be given by informal carers or at least supported by them.

German Law, among other factors, induces informal care on this large scale, since the Law stipulates that every person is to be covered by long-term care insurance – but not to the full extent. The consequence is that services which cannot be financed this way have to be financed in other ways or provided by other means, for example by family carers. However, the German law does offer a broad spectrum of support available to informal carers in order to facilitate informal care (more ...)

Governance and financing of LTC

The German long-term care system is based on three institutional levels of governance and financing and is imbedded in the fundamental state principles of federalism and subsidiarity. The different political administrative levels take responsibility for different legislative and executive duties. According to the federal construction of the German Constitution, the governmental administrations act at a federal, a state (Länder) and at a local level. The Federal Government and the Governments of the States have a legislative function while the local authorities are responsible primarily for executive implementation. Local authorities in particular have a duty to avoid disparities in support and to ensure a regular supply of long-term care in every region of Germany. This takes into account the contribution of all local, state-owned, and non-profit-making care institutions and private enterprises. Statutory long-term care insurance (LTC) (Soziale Pflegeversicherung, SGB XI) is the most important programme in long-term care and constitutes the ‘fifth column’ of the social insurance system as implemented in 1995, along with statutory health, accident, unemployment and pension insurance schemes. All of these are organized within a ‘Bismarck type’ welfare system (Esping-Andersen, 1990). The foundations of such central institutions as Social Health Insurance (Krankenversicherung) date back to the 19th century.

The remit of the long-term care insurance scheme is to ensure the provision of care for the insured and the quality control of   care delivered. Nevertheless, the scheme’s ability to ensure the supply of care is limited by the fact that it has no appropriate bearing on the creation, promotion or maintenance of an LTC infrastructure. This task is assigned to the federal states and municipalities and is decreed in special acts and regulations, e.g. the (Retirement) Home Act (Heimgesetz) or the Assistance Act for Senior Citizens (Altenhilfe, § 71 SGB XII).  Indeed, the concept of a corporate model in terms of “managed care” or “integrated care network” is lacking. A move towards a “competitive market” was promoted by recent reforms in favour of more market-oriented mechanisms. Thus, health and long-term care systems are still characterized by a mix of autonomy and interdependence regarding the different professional interest groups, featuring competitive negotiation processes between them.

However, these diagnostic findings are only true for the Western federal states, the former German Federal Republic. After World War II, the East German health care system underwent radical changes, which cannot be described here in detail, but still affect present health policies in the reunified health care system after 1989.

Since care for older people is regarded as an upcoming social challenge, the issue of long-term care currently receives considerable attention in the context of concerns about the affordability and sustainability of care in an ageing society. There is a societal and political consensus regarding the need for quality care of older people, protecting their dignity, coupled with recognition that great efforts will be required to uphold these values (more …)