Innovating European Long-Term Care Policies through the Socio-Economic Support of Families: A Lesson from Practices

Abstract

LTC and socio-economic deprivation of families are two relevant issues in international debate. The economic or time investment made by families in caregiving has an impact on the socio-economic status of family members in terms of economic means and social inclusion. This study analyzes the practices that are supported by home LTC, examining their characteristics, identifying their strengths, weaknesses, drivers, and barriers, as well as identifying social innovation aspects. The study provides a qualitative interpretative comparison of 22 practices from eight countries, representing the four LTC care models existing in Europe. Cross-studies aid in the development of sustainable policies. The study highlights the differences and similarities between selected practices. The results indicate the effectiveness of integrative and coordination strategies at the macro, meso, and micro levels for the development of supportive policies for family members with burdens of care. Nevertheless, the results underline the lack of a genuine focus on families’ socio-economic support for providing care. The partial support provided by compensatory cash benefits or unpaid care leave schemes partially addresses the difficulties of familial burden of care. The study recommends that fair economic compensation and social security benefits be incorporated into innovative and sustainable strategies for supporting caregiving in LTC and welfare schemes.

1. Introduction

Population aging is one of the most significant challenges today. According to the World Health Organization [1], by 2050, the proportion of the world’s population aged 60 years or over is expected to nearly double from 12% to 22%, reaching 2.1 billion older adults, while the number of people aged 80 years or older is expected to triple in the same period, reaching 426 million. The international economic crisis of the last two decades has highlighted the risks of poverty and socio-economic deprivation in Europe [2,3]. The significance of these issues has been further intensified by the recent COVID-19 pandemic. Containment measures for COVID-19 had a detrimental effect on global economic growth and productivity, increasing the risk of poverty and social deprivation [4].

Moreover, the vulnerability associated with the aging process was exacerbated during confinement. Older adults are seen as a high-risk group for the SARS-CoV-2 (COVID-19) disease [5]. Data indicate that the over-65 population accounts for 80% of hospitalizations and faces a 23-fold increased risk of death compared to those under 65 years of age [6]. Social isolation, as a primary measure for preventing the spread of COVID-19, resulted in an increase in informal caregiving provided by families [7].

The challenge for policymakers is to address population aging and the increasing number of frail older people in need of long-term care, while also taking into account the impact on families in terms of their social inclusion and risk of socio-economic deprivation [8]. In addition, despite the fact that relatives continue to be the main caregivers for elderly people in a state of dependency [9], changes in demographic and social patterns may lead to a decrease in family support, which is typically the most critical source of support for older adults in a state of dependency in most systems [10,11].

Over the last decade, the international debate has emphasized the importance of home care in promoting social innovation (SI) in LTC because living at home supports the quality of life of older people while improving the efficiency of care provision [12]. The literature underlines how caregiving intersects with the gender issue, increasing its relevance as a social inclusion topic: women are the primary informal carers [13,14]. Moreover, caregivers’ financial well-being, employment and, indirectly, their financial income may be negatively affected, increasing the risk of poverty [15]. The different European LTC models are distinguished by their internal balance of formal and informal care provision [16]. European LTC systems are being put to the ultimate test by sociodemographic and social changes, as well as welfare austerity, as a result of the international economic and public health crisis [17,18,19]. In 2017, Mosca and colleagues emphasized the relevance of cross-studying existing policies in order to build a new sustainability strategy for the European LTC system [20]. The purpose of this article is to analyze a sample of practices in Europe that support the long-term care system in order to examine its innovative aspects to counter the risk of socio-economic deprivation of the elderly and their families. The study takes part in the framework of the “Socio-Economic deprivation related to the effect of the presence of dependent older people: strategies for Innovative Policies in Europe” (SEreDIPE) project, realized thanks to the Marie Curie Individual Fellowship (g.a. 2019-888102), aims to analyze the effects of older people’s care needs (aged 65+ years) on their family units’ socio-economic conditions. The SEreDIPE project’s conceptual framework recalls how families with dependent older people often invest in care-giving by directly purchasing care provisions, such as those provided by Migrant Care Workers (MCW), or by providing informal care, even at the expense of available working hours [21]. Both strategies may have an effect on the family member’s socio-economic status in terms of economic resources and social inclusion [22]. The literature underlines how an LTC system relying on informal care and migrant care work is neither equitable nor sustainable [13,14].

The study begins by identifying the main characteristics of selected policies, including whether the policies’ stated objectives explicitly include support for beneficiaries’ socio-economic conditions. Additionally, the study proposes the analysis of strengths, weaknesses, drivers, and barriers to policies. Finally, this investigation enables us to denote which policies meet one or more of the social innovation requirements for LTC. In accordance with the SEreDIPE project’s recommendations, this study collects policies from eight European countries representing the four LTC care models existing in Europe: Italy and Spain to describe the family-based care regime; Germany and Austria for the mixed-care regime; the Netherlands and Finland representing the universal care regime; and Romania and Poland for the transition countries’ care regime [23]. The recent literature focuses the attention on innovation on LTC [12,23] national case studies [10] or on a specific typology of policy [13,14,17]. This study contributes to the literature by offering an overview of the innovative characteristics of policies supporting families providing care from a comparative perspective.

2. Materials and Methods

This study uses a qualitative methodology to examine existing practices in Europe that address the care of people over 65 years of age, who are in need of long-term care, and are in a state of dependency.

A descriptive interpretative approach was applied in order to provide an in-depth understanding of relationships between policies supporting home LTC and the risk of socio-economic deprivation for families. The comparative qualitative approach was deemed the most appropriate for capturing the specific characteristics of each in the good practices while allowing researchers to embrace their own disciplinary orientation [24].

The study identified policies from eight European Union countries (Germany, Poland, Romania, Austria, Italy, Spain, Finland, and The Netherlands), representing the four European LTC systems. Two main selection criteria were adopted: (a) The initiatives must participate in the studied country’s LTC policies; (b) The initiatives must also strive to directly or indirectly mitigate the risk of socio-economic deprivation of the care recipient and/or his family caregiver. The selection excludes formal home care services and residential care because they are not innovative forms of services.

Multiple sets of searches were conducted from June to September 2021 to cover the cases of countries included in the study. A set of keywords were used to select the practices for each of the eight studied countries: LTC policies, home care, informal care, and cash benefits. The search was mainly carried out in English, but also in the national languages to ensure collection accuracy and to find each country’s specific legislation or policy documentation.

Two of the authors (M.F.S., G.C.) provided native speaker translations of the keywords and data in Italian and Spanish. DeepL, a machine translator which is considered by the literature as a tool providing adequate translations for content qualitative analysis [25,26], was used to translate English to German, Finnish, Romanian, and Polish. The translation of collected documentation followed the same procedure based on the automatic translation by DeepL, from national languages to English. The Italian and Spanish translations had integrative checked by the above-mentioned native speaker authors.

In addition, the reading of available European research reports from the last five years (e.g., “European network on long-term care quality and cost-effectiveness and dependency prevention”, and the project Mopact—Mobilizing The Potential of Active Ageing in Europe) was incorporated into the search for good practices.

A total of 22 practices were included in the study. Data collection was completed in English following a double stage of descriptive and analytic summarization of data on initiatives. To begin, each policy was summarized by its descriptive form, including eight dimensions: name, country, aims of the initiative, target, a summary of the initiative, type of initiative, and social innovation characteristics. The different SI characteristics for LTC are defined using the conceptualization provided by recent literature [12,27,28] which identified four different areas to promote social innovation in LTC: (a) new policies or revised policies to better meet social and LTC needs; (b) openness of the beneficiary’s target in particular to informal carers; (c) support beneficiaries’ quality of life (QoL); (d) promote collaboration between stakeholders and services. The collection of specific data on each practice comes from national reports on LTC policies experiences (e.g., ESPN Thematic National Reports on Challenges in LTC, CASE Network Studies and Analyses), European reports projects (e.g., “European network on long-term care quality and cost-effectiveness and dependency prevention”, and the project Mopact—Mobilizing the Potential of Active Ageing in Europe).

Table 1. Analytic characteristics, modalities, and coding.

Dimensions	Modalities (Synthetic Code)
Name of action/intervention	-
Year	-
Country	Italy (IT); Spain (ES); Germany (DE); Austria (AU); Finland (FI); Netherlands (NL); Poland (PL); Romania (RO).
Target population	Older people 65+ (1); People 75+ (2); working carers (3); Informal carers (4); Population in a state of dependency (5).
Type of initiative	Cash benefits (CB); Vouchers or cash benefits bound to specific types of costs (V); Support services (SS); Care leave scheme (CL); Fiscal and social security benefits (FS); Job Agreements (JA).
Level of governance	National (Nat.), Local (Loc.).
Level of implementation	National (Nat.), Local (Loc.); Municipality (M).
Included in LTC program or national reform	Yes (*)/No (-).
Existence of aims directly related to improving socio-economic conditions	Yes (*)/No (-).

detailed the coding of characteristics’ modalities used to perform the analytic summarization of the data.

3. Results

3.1. General Characteristics of Initiatives

The comparative analysis of the twenty-two initiatives makes it possible to observe that the initiatives studied are based on lengthy implementations (

Table 2. General characteristics of selected practices: year of implementation, type of policy, governance and implementation level, and declared goal of supporting SE condition.

No.	Initiative Name	Year	Type	Target	Gov.	Implem.	National Policy	SE Condition’s Goal
1	Voucher scheme for home care (DE)	1995	V	1	Nat.	Nat.	*	-
2	Allowance scheme for informal care (DE)	2015	CB	1	Nat.	Nat.	*	*
3	Social security benefits for family care givers (DE)	2015	FS	4	Nat.	Nat.	*	*
4	Long-term care allowance (Pflegegeld) (AU)	1993	CB	1	Nat.	Nat.	*	*
5	“24 h care allowance”(AU)	2007	V; FS	1	Nat.	Nat.	*	*
6	Care leave for working carers (Pflegekarenz) (AU)	2014	CL	3	Nat.	Nat.	*	-
7	Care leave benefit (AU)	2014	CB	3	Nat. + Loc.	Loc. (M)	-	*
8	Care benefits (dodatek pielęgnacyjny) (PL)	2003	CB	2	Nat.	Nat.	-	*
9	Nursing benefit (zasilek pielegnacyjny (PL)	2003	CB	4	Nat.	Loc.	-	*
10	Nursing allowance for informal care (świadczenie pielegnacyne) (PL)	2003	CB	4	Nat.	Loc.	-	*
11	Voucher scheme for home care (RO)	2000	V	1	Nat.	Nat.	-	*
12	Care allowances (RO)	2011	CB	1	Nat.	Nat.	-	*
13	Facilities for mobility and communication (RO)	2000	SS	1	Nat. + loc.	Loc. (M)	-	-
14	Occupational welfare schemes (IT)	2016	V; CL; FS	3	Nat.	Nat./Priv.	-	-
15	Cash benefit for informal care (IT)	1995	CB	1;4	Nat + Loc.	Loc. (M)	-	*
16	Care allowance (IT)	1980	CB	1	Nat.	Nat.	-	*
17	Financial benefit linked to the service (ES)	2006	V	5	Nat.	Loc.	*	*
18	Financial benefit for the purpose of care in the family setting and support for non-professional caregivers (ES)	2006	CB, FS	5	Nat.	Loc.	*	*
19	Financial benefit for personal care (ES)	2006	CB	5	Nat.	Loc	*	*
20	Care allowance for pensioners (FI)	n.a	CB	1	Nat.	Nat.	-	-
21	Informal care support (FI)	2005	CB; FS, SS	4	Nat.	Loc. (M)	-	*
22	Care leave scheme (NL)	n.a.	CL	3	Nat.	Nat.	-	*

). Except for the Italian system, none of the systems presented initiatives after 2014. Likewise, we can observe that different countries (Germany, Austria, and Italy) have implemented recent policies in their long-term care systems, currently maintaining initiatives established in the 1990s and even in the 1980s, as in the case of Italy. Traditionally, institutions provided a cash benefit policy to promote financial support for care. Even now, this type of policy is the most common in Europe: 11 out of the 22 policies studied involve cash benefits. All countries have developed initiatives focused on providing financial benefits to help mitigate the costs associated with long-term care. These initiatives offer a fixed amount to the measure’s beneficiaries. The inclusion criteria differ from initiative to initiative and from country to country. Generally, cash benefit policies are not means-tested. The results underline how cash benefit policies are independently run by other LTC policies: the only exception is the Finnish initiative “informal care support”, which offers financial benefits and support services together with cash benefits. However, the initiatives in three countries are included in specific national programs, such as the national LTC insurance scheme (Germany) or a distinctive national reform on LTC (Spain and Austria).

Even the financial benefit linked to covering specific costs (V) stands out as one of the more commonly used types of initiatives (5 out of 22). The Spanish “financial benefit linked to the service” offers financial support for paying for a specific service when the person cannot access a public or concerted care service. In Germany, the voucher scheme supports home care buying and participation in national LTC insurance. Differently, in Austria, the “24 h care allowance” promotes the integrated scheme, including vouchers to support the cost of hiring migrant care workers (McW) and fiscal and social security benefits. In Germany and Spain, social security benefits are ensured for informal carers through specific measures included in their national schemes. A mixed scheme of policies is also supported by the recent Italian occupational welfare scheme, which allows working carers to access different policies (e.g., vouchers for care, fiscal and social security benefits, and care leave).

Care leave experiences from Austria, Italy, and the Netherlands ensure that working carers are given the attention they deserve. The main aim of these measures is to improve care-work compatibility, allowing workers to provide informal care.

When it comes to beneficiaries, most of the initiatives are focused on care recipients, even if they are only potential: ten initiatives are dedicated to older people (65+), two are focused on the oldest-old (75+), and three on dependent people without reference to a specific age. This last characteristic can be seen in the initiatives implemented in Spain, highlighting a facet of Spanish strategy. In Germany, Poland, Finland, and Italy, five initiatives are directly oriented towards informal carers, while policies supporting working carers are implemented in Austria, Italy, and the Netherlands.

Table 2 depicts how most of the initiatives under examination are national measures characterized by national governance and implementation. The main exceptions are related to the Spanish and Italian initiatives. The Italian and Spanish decentralized social protection systems promote a multi-level governance and implementation, even for cash benefits, vouchers, and care leave policies. In these countries, the implementation of initiatives is realized at the local level by regional institutions and municipalities. Moreover, the private sector is involved in the implementation of Italian occupational welfare schemes [29]. Finally, the Austrian “care leave benefit”, the Romanian facilities, and the Polish nursing benefits promote multi-level governance (national and local) to support local implementation [30,31,32].

The findings emphasize the objective of supporting beneficiaries’ social-economic condition: 17 out of 22 selected practices aim to provide economic support for the provision of formal or informal care. The German voucher scheme and the Finnish “care allowance for pensioners” highlight the opportunity to use it to purchase LTC services, but do not state that the mitigation of material deprivation underpins this policy [33,34]. Likewise, the aims of Finnish and Austrian care leave schemes or the Italian “occupational welfare scheme” focus more on workers’ work-family life balance than on the indirect effect of beneficiaries’ socio-economic conditions. Five countries offer social security benefits for informal carers (FS), ensuring social security support for carers who are relatives. Germany and Spain recognize the entitlement to pension rights covered by a national social security system. Under Finnish schemes, informal care by a care worker is covered by an entitlement to receive a cash allowance, social security benefits, and days off.

3.2. Analysis of the Strengths and Weaknesses of Practices

The interpretative analysis of practices provides several outcomes on strengths, weaknesses, drivers, and barriers, which are summarized in

Table 3. Strengths and weaknesses in the practices examined.

Strengths	Initiative No.
a. Oriented towards informal carers for their social inclusion.	2, 4, 16, 19
b. Focuses on working carers.	7, 8, 22
c. Promotes a new definition of informal carers, including friends and neighbors. It promotes a shared responsibility of informal care.	21
d. Reserved for beneficiaries not included in other measures.	9
e. Universal measure to cover unmet needs.	10, 12, 14.
f. The policy promotes flexible and integrative solutions to support care.	1, 2, 4, 5, 14, 15, 17, 18, 19, 21
g. Promotes the interaction of health support and welfare schemes.	7, 14
h. Promotes a minimum wage for providing care.	7, 8, 21
Weaknesses	Initiative No.
i. Low benefit amount/partial cover of care costs.	4, 6, 9, 10, 16, 20, 21
ii. Not linked to household minimum income.	1, 2, 3, 6, 9, 10, 15, 16, 17, 18, 19, 20, 21
iii. Care recipient is the exclusive beneficiary of measures.	1, 2, 4, 5, 8, 9, 11, 12, 17, 18, 19
iv. Initiative is tailored on an individual basis.	8, 9, 10, 11, 12, 13, 14, 15, 16, 20, 22
v. Inclusion criteria de facto promote the exclusion of high-need targets (e.g., marginal workers).	6, 7, 22
vi. Temporary and fragmented.	14, 15
vii. Compulsory universal insurance scheme with a direct impact on the beneficiary’s income and eligibility (e.g., criteria include extra cost for childless people).	1, 2, 3
viii. Daily leave is not included in the leave scheme.	7, 22

and

Table 4. Drivers and barriers in the practices examined.

Drivers	Initiative No.
a. It is part of national reform/legislation.	1, 2, 3, 4, 5, 18, 19, 20, 21
b. It is subjected to periodic review.	1, 2, 3
c. National measure.	1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 14, 16, 20, 21, 22
d. Direct benefit included in social security or pension schemes.	6, 8, 22
e. Different stakeholders are involved in its implementation(e.g., municipalities, NGOs, private enterprises, and companies).	5, 14, 21, 17, 18, 19
f. Coordinated multi-level governance of measure (national + local).	7, 13, 15, 17, 18, 19
Barriers	Initiative No.
i. Culture of care: informal care is mostly the responsibility of families.	8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19
ii. Culture of compensation for the care recipient’s incapacity.	17, 21
iii. Culture of fragmentation and separation of LTC issues.	8, 9, 10, 11, 12, 13, 14, 15, 16
iv. Separation between governance and implementation.	9, 10, 13, 14, 15, 16, 21

. Many of the policies examined find at least one of their strengths in the definition of the target because they include informal carers and working carers as direct beneficiaries of dedicated care allowances and care leave schemes. In addition, in Finland and recently in Germany, the care allowance for informal care allows neighbors and friends to be considered informal carers, in addition to family members of care recipients. Lastly, the Polish “nursing benefit” is dedicated to older people who do not receive care allowances, thus covering a need that is not covered by other policies. The strengths of some schemes are tied to meeting an unmet need in their respective countries. In Poland, Romania, and Italy, which are characterized by the family’s strong duty to provide care [35,36,37], the allowances for care work cover an unrecognized need.

Many initiatives (10 out of 22) are seen as “integrative and flexible action” because they include multiple types of interventions or dialogues with other national policies or welfare schemes (Table 3). The Finnish experience proposes internal integration, while Austria, Germany, and Spain, the latter to a partial extent, proposes the external coordination of different policies.

In Austria’s case, additional financial assistance is granted over and above the LTC cash benefit for people with high care needs requiring 24-h care and who qualify for LTC cash benefits, if they fall below a specific income threshold. The system distinguishes between care provided by a self-employed carer (around 300 euros/month) and care provided by a carer employee (double the amount).

A part of the Austrian Pflegegeld benefit is dedicated to informal carers. This measure is based on seven categories of amounts ranging from less than 200 euros/month to an amount of up to 1600 euros/month, depending on the care needs and the burden of care provided.

Moreover, if a caregiver (providing care for the duration of at least one year) is unable to work for 1 to 6 months due to the provision of care, the care leave benefit can be availed of (for 1 to 6 months) (EC, 2018) [31]. The benefit is a wage replacement equivalent to 55 percent of the daily net income (like the unemployment benefit), with a minimum amount corresponding to the minimum wage (up to 400 euros/month) [38].

Altogether, the design of the Austrian initiative promotes the concept of a minimum wage for providing care. In Finland, the extent of informal care support defines the amount of benefits depending on whether the informal caregiver is able to work or otherwise, due to heavy care obligations.

Support is treated as taxable income and it accrues pension rights. A Finnish informal carer doing demanding care work gets three days off per month (EC, 2018f) [34].

The analyzed practices highlight certain weaknesses in the practical response to the initial necessity for which they were created: many schemes, particularly cash benefits, do not fully cover families’ formal or informal care (Table 3). Moreover, in almost half of them (10 out of 22), the care recipients remain the single beneficiaries of benefits, even if the measure targets informal care. Generally, compensation policies are not designed to take household income into consideration. Local institutions in the Spanish and Italian decentralized welfare systems promote a diverse amount of benefits on a region by region basis, based on locally-defined income criteria [35,39]. These decentralized systems produce temporary and fragmented policies. In particular, in Italy, the cash benefit for informal carers is determined on an annual basis by local institutions, and the implementation of an occupational welfare scheme for LTC is left to the voluntary action of private companies, which have free rein on what kinds of services and benefits to include in their welfare schemes and criteria of use.

In countries with high familial responsibility for care provision (Italy, Spain, Poland, and Romania), the initiatives suffer from a weakness related to their being individually tailored, with little connection to other LTC or welfare measures.

In the German LTC insurance scheme, the main weakness is the direct impact of insurance payments on the individual income of all working-age and pensioner citizens. The insurance covers around 2–3% of an individual’s gross income. Childless people must pay an additional 0.25%, while children and spouses earning less than EUR 450 per month are co-insured at no extra cost [33].

Compared to initiatives targeting working caregivers, the levels of care measures are characterized by a different internal definition, which generally does not include daily care permits. The option is not even included in the Austrian scheme, implying a lack of economic compensation through the care leave allowance. Furthermore, self-employed workers are not eligible for care leave schemes, resulting in their exclusion from support measures.

3.3. Drivers and Barriers in the Practices Examined

Aspects of implementation contexts influence the effectiveness of policies. In this regard, the results identify the national characteristics of measures as the main drivers for almost all the initiatives examined (Table 4). This aspect ensures that measures are disseminated throughout the territory and reach the intended beneficiaries homogeneously. In the German case, moreover, measures were periodically reviewed. This is another driver because it allows measures to be adapted to changing social needs.

Another facilitator is related to automatic access to benefits: if, generally, care leave initiatives are included in social security schemes, the nursing benefit in Poland is automatically added to pensions.

Finally, the involvement of the various stakeholders in the policies supports their implementation, thus strengthening mutual collaboration for the achievement of common objectives. In this regard, the Spanish reform calls for collaboration and coordination between national and regional institutions for the planning and governance of measures: the Autonomous Communities (regional institutions) are called upon to debate and consult with national ministries on the final implementation of the measures included in the national LTC Law (Ley de Dependencia) [39,40].

In the Italian occupational welfare scheme, the private sector is called upon to participate as an implementer of the policy, spreading awareness on rights to care support.

On the other hand, in some cases, the municipalities, which are fully delegated to implement the measure, independently define the eligibility criteria and internal characteristics of benefits, de facto reducing the number of beneficiaries (e.g., the Finnish informal care benefit) or producing local inequities (e.g., the Italian and Polish informal care benefits). In this case, the separation between governance and implementation seems to have become a barrier to the policy’s effectiveness. Furthermore, this study shows that two cultural barriers still exist with regard to the development of innovative policies in the LTC sectors to support families and their socio-economic situation. In Italy, Spain, Poland, and Romania, the centrality of families in providing care is enshrined by formal law and cultural rules. The allocation of a compensation allowance recognizes the role of the informal care provided, but without a concrete valuation of the burden’s economic and relational impact for relatives.

3.4. The Social Innovation Aspects of Selected Initiatives

The analysis confirmed the applicability of the areas identified in the literature for promoting social innovation in LTC. Most of the practices examined meet at least one of the four areas.

Table 5. The selected initiatives’ social innovation aspects.

Social Innovation Aspects in the Policies	Initiatives
(a) It is a new policy or a revised policy to better meet social and LTC needs.	1, 2, 3, 7, 14
(b) It targets beneficiaries.	6, 7, 10, 14, 15
(c) It aims to support beneficiaries’ QoL.	5, 6, 7, 22
(d) It promotes new relationships between stakeholders.	5, 14, 17, 18, 19, 21
(e) Lack of social innovation aspects.	8, 9, 10, 11, 12, 16

outlines how social innovation in these practices is driven by the formal identification of informal and working carers as specific beneficiaries of initiatives (5 out of 22) and by the design of policies to improve their quality of life (4 out of 22). In this regard, the Austrian scheme based on a minimum wage for informal care includes both of the above innovative characteristics.

Five schemes were recently implemented: the three German practices stem from a review of the periodic insurance scheme, while the Austrian care leave benefit and the Italian occupational welfare scheme are new policies. In six cases, the stakeholders involved in a single initiative could produce specialized networks and new mixed collaborations for future policies. In contrast, active Polish and Romanian policies do not present any innovative aspects. However, innovative LTC policies have largely been debated in Romania and are included in a reform program that was drafted in 2018, but has not yet been implemented.

4. Discussion

The results show that, on the one hand, long-term care initiatives are recent, as the first major initiatives or transformations in long-term care policies occurred in the last three decades. On the other hand, there are many variations and differences between countries. This variability may be the result of various aspects. Firstly, the different definitions of long-term care that are used in Europe and which are characterized by a different valorization of health or social care [41]. Similarly, the country by country variability depends on different welfare state and care regime models [42]. Finally, different welfare cultures may influence the perception of recent social risks stemming from care needs [43,44].

Furthermore, this study highlights how initiatives promoting reconciliation between family and work-life are recent. This result is linked to the spread of the culture of family care responsibility existing in many European countries. In this case, the younger female member of the family often serves as the caregiver for all other family members [45]. In relation to this, the low number of non-economic measures observed in this study supports the assumption that policymakers do not recognize the impact of informal care on care recipients’ quality of life and the overall quality of care provided.

All these factors can directly influence the development of initiatives focused on long-term care for the dependent population, both in terms of the products, services, and benefits offered as well as the target population group. However, in many European countries, the strategy for designing policies to support families in providing informal care is still based on the standard compensation awarded by national cash benefits. This strategy, traditionally based on compensation for care recipients’ incapacity, does not meet the goal of countering the socio-economic consequences of care being provided by informal caregivers. Indeed, cash benefit policies become effective if they are integrated with other public policies and services [46].

The results reflect the effectiveness of integrative and coordination strategies at the macro, meso, and micro levels for the design of supporting policies for those family members providing care. At the macro level, coordination between different policies may become a driver if they are included in a national action or reform on LTC. This enables the design of a comprehensive system of policies to fully meet the care needs of recipients, while also taking into consideration the other social needs of families and care workers [28,47]. At the meso level, the involvement of different stakeholders is characterized by collaboration between local and national institutions. A mixed framework of design and governance helps to overcome some key barriers for establishing long-term care and welfare systems [48]. In this regard, two good examples are the Spanish reform on LTC and the German insurance on LTC, even with internal differences. Moreover, the participation of private companies and enterprises to realize specific policies for working carers is an opportunity to promote, even in countries with high familial responsibility, a culture of informal care that can appreciate and enhance the social identity of familial caregivers [49].

Implementing specific policies for informal or working carers integrates the LTC initiatives for the care recipient at the micro level. Nevertheless, informal care support is publicly stated but not fully realized when the policy is designed around care recipient characteristics. In this regard, the findings highlight the lack of actual orientation to socio-economic support for families providing care. Partial support provided through a cash benefits compensatory approach or unpaid care leave schemes does not fully respond to the difficulties of familial burden of care. In countries with a high familial responsibility for care, the family remains the main care provider without adequate support.

The parallelism between the objectives of the practices and the objectives of social innovation highlights how the development of these family assistance policies is one of the main ways to innovate the LTC and welfare systems. The Austrian scheme with the minimum wage for assistance is promising, but the figure of around 400 euros does not correspond to a pay that is linked to the cost of living. The suggestion is more accurate for many Italian local schemes, where the amounts for caregiving are defined in 200 euros/months.

In this regard, the results suggest that the right to receive fair economic compensation and social security benefits must be included in the design of welfare and LTC policies to support families in providing care. This innovative approach emphasizes the urgent need to break down cultural barriers to family responsibility and respect and remove the divide between social and health policies. To achieve these goals, some local Italian institutions design allowances for informal care with a progressive amount from 500 euros to 1100 euros depending on the level of care needs (e.g., Puglia Region and Trento Municipality)

5. Conclusions

This study analyzes support practices concerning family caregivers in different European countries, highlighting how these policies’ effectiveness is also linked to their ability to counteract the adverse socio-economic effects of informal care for families. The results confirm how the adverse effects of providing care are still undervalued in policy design. The overview of different policies revealed a common strategy based on standard remuneration for informal care and schemes for working carers based on the level of care provided. In this scenario, families remain the main providers of home care, receiving only partial support from welfare and LTC schemes. It is, therefore, recommended that the right to receive fair economic compensation and social security benefits is included in the innovative and sustainable strategies for LTC and welfare schemes.

Finally, some limitations should be considered with regard to this study. To begin with, the lack of an international classification system that would allow for a standardized coding of the initiatives developed in different countries makes comparisons challenging. Moreover, the collection of policies was not checked with the help of experts from the countries under study. Multiple search step strategies reduced the risk of potentially not finding data, but the difficulty in locating updated data on individual practices suggests that further multiple research team studies, including with other countries, should be encouraged. Specifically, the realized desk collection of data by grey literature and literature did not allow to collect updated data (e.g., the different cash benefit amounts) useful to evaluate the effectiveness of practice because the data are not declared or not updated. Furthermore, multiple site studies will allow an in-depth analysis of how the practices work, taking into consideration specific welfare and LTC system characteristics. Despite these limitations, this study provides a general framework of the characteristics of active European LTC practices for supporting families caring for dependent people, with a focus on their effectiveness in overcoming adverse socioeconomic effects, as well as useful suggestions for the international LTC and welfare debate.