The population of Germany is one of the oldest in the European Union. In 2019, 17.9 million people were aged 65 and over, amounting to 21.5 % (EU: 20.3 %) of the total population (83.0 million). In the period 2017-2050 the share of 65+ people in the German population is expected to grow from 21.6% to 28.3% (EU-28: 20%-28.5%), with most of the growth occurring before 2030. At the same time, the share of 85+ will expand by more than a factor 3 (from 2.7% to 6.6% / EU-28: 2.7%-6.1%).
Over the same period, the old age dependency ratio measured as the proportion of 65+ as a percentage of the 15-64-year-olds will rise from 32.8% to 64.6% (EU-28: 30.5% to 55.3%). Life expectancy for men and women at age 65 is projected to rise from 13.8/18.5 years (EU-28: 17.2/20.7) to 18.5/22.7 years (EU-27: 22.4/25.6) between 2018 and 2060.
Estimates of the number of LTC dependent elderly in 2030 ranges from 3.17 to 3.37 million. By 2050 around 4.4 million people are expected to be in need of LTC.
Under an assumption of no policy change the Ageing Report scenario suggests that public expenditure as share of GDP would rise from 1.3% to 2.7% (EU-27: 1.6%-3.1%) by 2070. The impact of a progressive shift from the informal to the formal sector of care in Germany would entail an estimated increase by 178% in the share of GDP devoted to public expenditure on long-term care (128% on average for the EU27).
LTC in Germany is based on a long-term care insurance (LTCI) principle. Anyone living in Germany is obliged to take up LTCI (Pflegeversicherung), either in the statutory or private LTCI system. In LTCI, the ‘LTC insurance follows healthcare insurance’ principle applies, i.e. all statutory health insurance members are, in general, automatically members of the statutory LTCI and all members of a private health insurance are members of a private LTCI. The services provided by private LTCI are equivalent to those offered by statutory LTCI. By the end of 2018, 72.75 million people (around 89 % of the population) were insured under the statutory LTCI scheme, while 9.24 million (around 11 %) held a private LTCI policy.
Statutory LTC insurance is financed through income-related contributions paid equally by employers and employees. LTCI covers only part of LTC costs. The amount received varies depending on the degree of care and the type of benefit provided. If the persons in need of care – or under certain conditions their immediate family members – are not in a position to bear the uncovered costs themselves, the remaining amount must be paid by social assistance grants, i.e. by the municipalities.
LTC benefits are granted on the basis of a care grade and of the care arrangements (either at home or in a residential care setting). According to the law, people are eligible for LTC if, because of a physical, mental or psychological illness or disability, they require frequent or substantial assistance with a specific set of activities of daily living and instrumental activities of daily living for an estimated period of six months or longer. All dependent people (children with disabilities, adults and older people) are eligible for the LTCI care scheme, irrespective of their age.
Access to benefits was significantly expanded from 2017. Since then, the entitlement to benefits is banded into five care grades based on physical, mental and psychological disabilities. Accordingly, the condition of being ‘in need of care’ is determined by the degree of the individual’s autonomy, i.e. by impairments of independence or incapacitation in six fields (modules), which are weighted as follows: mobility (10 %), cognitive and communicative abilities, behaviour patterns and psychological problems (15 %), level of self-sufficiency (40 %), health restrictions, demands and stress due to therapies (20 %) and structure of everyday life and social contacts (15 %). The grade of care is determined by the Medical Services of the Statutory Health Insurance Funds (Medizinischer Dienst der Gesetzlichen Krankenversicherung – MDK) or by its private counterpart.
Generally, there are three different arrangements through which a beneficiary can receive long-term care: a care allowance, (in kind) home care services and residential care. The care allowance relates to informal care, i.e. the person in need of care only receives financial support, typically lives at home and is cared for by close relatives. In-kind home care means that a professional care provider regularly visits the recipient at home. The provider is directly paid by LTCI (unless the care received exceeds the appropriate level of benefits in which case the difference is borne by the care recipient). Residential care refers to either short-term or long-term stay in a nursing home.
In 2016, according to a survey, 24 % of households that categorising themselves as in need of LTC did not use professional home care services either for financial reasons (19.2 %) or because services were not available (3.8 %). More recent data from the Federal Ministry of Health for 2018 shows that most of the people in need of care who receive benefits or services from statutory LTCI are in receipt of a care allowance; this applied to 48.3 % of all recipients in 2018 (including combined benefits: 62.1 %).
Besides the core benefits, there are additional benefits provided under LTCI, for example:
- Holiday stand-ins/respite care: if the person who provides care at home goes on holiday or is otherwise unable to provide care, people in need of care are entitled to a stand-in for a maximum of six weeks a year.
- Part-time institutional day and night care: part-time residential care refers to care in a facility that provides day or night care. The LTCI fund pays the costs of care, social support and medical treatment.
- Short-term care: short-term care is provided in appropriate institutional facilities if the people in need of care only need full-time residential care for a certain period of time, notably to cope with crises in care at home or following a stay in hospital.
- Nursing aids (such as a special bed) and home conversion grants to accommodate the nursing care needs.
- Nursing care courses for relatives (advice for informal carers).
- Case and care management (advice and counselling for persons in need of LTC and informal carers)
With regard to benefits, there are no differences between statutory and private LTCI.
Number of carers
Data about the number of informal carers in Germany greatly varies depending on whether we use official statistics, which is outdated and clearly underestimates the prevalence of informal care – or unofficial datasets which focus on self-reported informal care provision. According to official data, around 5 million people provide informal care to a dependent person in Germany (i.e. 4% of the total population). However, the data collected through the European Quality of Life Survey (2016) shows that Germany has one of the highest rates of self-reported informal care provision at around 22% of the total population – amounting to more than 18 million carers.
Identification of carers and assessment of their needs
Currently, the majority of people in need of care receive either a care allowance or home care in kind, which is in line with the principle “care at home prior to residential care”. The typical scenario is that either spouses or children between the ages of 50 to 65 years care for the beneficiary. Official numbers of these informal carers, i.e. persons caring non-professionally, are not available.
With Germany’s solidarity-based social insurance system, informal carers are covered by pension, unemployment and accident insurance. Employees who are released from work for a temporary period are subject to mandatory social insurance and retain their coverage across all areas of social insurance provision. In the case of complete release from work, the employee no longer works for pay. In the statutory health and long-term care insurance system, in addition to free family insurance, provision is made either for voluntary insurance or mandatory insurance under Section 5 (1) Number 13 of Book V of the Social Code (SGB V) and Section 20 (1) Number 12 of Book XI of the Social Code (SGB XI).
The statutory or private long-term care insurance fund pays mandatory contributions to a carer’s pension insurance fund for the period in which they care for one or more people in need of long-term care with at least care grade 2 in their home free of charge for at least ten hours per week, usually spread over at least two days per week, and are not gainfully employed for more than 30 hours per week as a rule.303 The care work performed is deemed unpaid if the carer does not receive remuneration for the care work in an amount which exceeds the amount of care allowance for a corresponding amount of care.
According to the provisions of Book VII of the Social Code (SGB VII), carers are insured under statutory occupational accident insurance (Section 2 (1) Number 17 SGB VII). The prerequisite is that the person in need of long-term care has at least care grade 2 and receives care for at least ten hours per week, usually spread over a minimum of two days per week.
The long-term care period is counted as an insurance period for unemployment insurance purposes. Contributions to unemployment insurance are paid by the statutory or private long-term care insurance funds to maintain entitlement to unemployment benefit during a period of care. Here again, the prerequisite is that the carer regularly takes care of a person in need of long-term care with at least care grade 2 in their home for at least ten hours a week unpaid, usually spread over at least two days a week. A further requirement is that the carer was subject to mandatory insurance immediately prior to the start of the care activity or was entitled to ongoing wage compensation benefit in accordance with Book III of the Social Code (SGB III).
Even if the carer is completely released from work, their health and long-term care insurance cover is maintained during the period of long-term care if they are subject to family insurance during the period in question. If this option is not available and there is no possibility of mandatory insurance, the carer must voluntarily take out further insurance with a statutory health insurance fund. In the event of a short-term absence from work (maximum ten days), membership in the statutory health insurance fund remains intact (Section 192 (1) Number 2 SGB V) during the period in which the carer’s grant is paid.
Since the generation between 50 and 65 years belongs to the so-called baby boomers, their number will increase in this decade. Therefore, there might be an increasing potential of informal care by family members. However, once the baby boomers will reach the age of 80 themselves, starting from 2025, family members will become rarer and thereby increasing demand for professional care is to be expected.
A special care situation is where children and adolescents look after relatives in need of long-term care. According to a survey conducted by the Centre for Quality in Care (ZQP), around 230,000 children and adolescents in Germany provide substantial and regular care for family members. Children and adolescents who care for close relatives in need of long-term care do not perceive themselves as carers. They take care of family members as a matter of course. They often worry a lot about their relatives who need help and care, have too little free time outside of attending school and providing care, are physically strained and have no one to talk to about their situation. This is why children and adolescents who are carers need special support. The first support programmes for caregiving children and adolescents are already in place. They are funded by the Federal Ministry of Family Affairs, Senior Citizens, Women and Youth, abbreviated BMFSFJ. The programme offers a low-threshold counselling service to support young carers country-wide and is designed to help them take breaks, reflect and take advantage of offers of help or to talk about their situation—including anonymously.
Training and recognition of carers’ skills
Given the concern about the quality of care delivered by informal carers, since 2008, LTCI organisations have been obliged to offer free training courses in LTC for family members and unpaid carers. People receiving informal LTC are required to make use of counselling services offered by accredited care facilities or counselling centres, in order to ensure the quality of such care.
Recognition and definition of carers
Carers are defined in German law (social law XI §19) as people who provide non-professional home care to other people in need of long-term care, due to a physical, mental or emotional illness or disability. Social protection services will only address the needs of carers if they provide at least 14 hours of weekly care to a care-dependent person.
Multisectoral care partnerships
Care coordination has for long been a major issue in LTC provision but a determined effort to overcome this problem was launched with the LTCI reform in 2008 which committed the various involved actors to secure a better coordination and integration of the involved systems. Also, as of 1 January 2009, every person in need of care obtained a legal claim to help and support through a long-term care counsellor. Counselling for persons in need of care and their relatives is provided by case managers employed by long-term care insurance funds at a long-term care support base or through qualified experts.
Access to information and advice
With Section 7a (1) of Book XI of the Social Code (SGB XI) introduced under the German Long-term Care Insurance Act (Pflege-Weiterentwicklungsgesetz), the entitlement to comprehensive advice tailored to the specific care situation was enshrined in national law. All insured persons who receive assistance from the statutory or private long-term care insurance funds or have submitted an application for assistance to a fund and have been officially recognised by that fund as in need of care-related assistance and advice, are entitled to receive free and unbiased advice. The mandate to provide information and advice applies to the statutory long-term care insurance funds, the private insurance companies offering mandatory long-term care insurance (with care advice being provided by a private care advisory agency, compass GmbH), the care support centres and—within the scope of (mandatory) advisory visits in the home (Section 37 SGB XI)—mobile care services. Also, Section 45 of Book XI of the Social Code (SGB XI) provides for nursing care training for informal carers. The provision imposes an additional responsibility on the long-term care insurance funds in that they are required to hold nursing care courses to familiarise practicing and potential volunteer carers with the duties involved in providing nursing care.
Although the requirement to provide advice was enshrined in national law with the Act to Strengthen Long-Term Care (PpSG), there was already a great need for advice even before this was done. Over the years, a large number of advice centres and models have been created and developed which vary greatly in terms of their staffing, time, spatial and financial resources as well as the qualifications of the advisers themselves. The advice centres are run by organisations such as welfare associations, local authorities, non-profits and self-help organisations.
Since 2011, the German Federal Ministry of Family Affairs, Senior Citizens, Women and Youth operates a counselling hotline (“Pflegetelefon”) for informal carers where information and advice can be obtained about all aspects of nursing care, including information about the right to benefits, assistance at home, respite, or counselling services among others.
Access to respite care
The Act to Reorient the Long-term Care Insurance (“Pflege-Neuausrichtungs-Gesetz” – PNG), which came into effect partly on the 30th October 2012 and on the 1st January 2013, improved a number of benefits, e.g. the benefits of respite care and short-term residential care for persons receiving care allowance. These benefits cover the following: If the informal carer gets sick or goes on holiday, for example, the LTCI pays benefits for up to four weeks of respite care or short-term residential care, but not more than 1,550 € per year, each. Since the PNG came into effect, the beneficiary of a care allowance still gets half of it during times of respite care or short-term residential care. Having said that, informal carers have to provide care for at least six months before benefiting from access to respite care.
Social inclusion of carers, access to education and employment
In order to balance the demands of care and work needs, employees are legally entitled, regardless of status, to reduce their working hours by at least 15 hours for up to 24 months, including a maximum of six months’ time off work (or below 15 hours per week). There is a guaranteed right of return from temporary part-time to full-time work or the working hours before having taken the leave. Employees taking up this scheme can claim a credit-financed benefit (interest-free loan) that has to be paid back in stages. In addition, employees are entitled to short-term care leave of up to 10 working days without prior notice. This right provides the opportunity to organise assistance and support when an acute care situation involving a close relative arises. The loss of income is compensated by a wage compensation benefit (carer allowance) amounting to 90 % of the lost earnings (minus employee contributions to the statutory pension, LTC and unemployment insurance, comparable to sickness benefit in the case of a child’s illness).
The entitlement to short-term absence from work is unlimited; it applies to every employee irrespective of the size of company. However, the statutory right to the six months’ care leave is limited to employees in companies with more than 15 employees. And the statutory right to work part-time for up to 24 months applies only to employees in companies with more than 25 employees. Those entitled are spouses, partners in accordance with the cohabiting partnership law or equivalent partnerships, siblings, parents, step-parents, grandparents, parents-in-law, children, children-in-law, adopted or foster children, adopted or foster children of the spouse or life partner, stepchildren, grandchildren, as well as brothers- and sisters-in-law.
Following the first report of the German Independent Advisory Board on Work-Care Reconciliation in 2019, in August 2022 the Advisory Board presented a further ‘interim report’ to the BMFSFJ (Federal Ministry for Family Affairs, Senior Citizens, Women and Youth), entitled Recommendations for Family Carers Leave and Family Care Allowance (Empfehlungen zur Familienpflegezeit und zum Familenpflegegeld). At the heart of these recommendations is the right to claim 36 months family care leave for each person requiring care. Six months can be full-time or part-time leave of absence. In the case of part-time leave of absence, the weekly work time can be below 15 hours in the first six months. For the remaining 30 months, a minimum work time of 15 hours per week is required. The maximum working time for claiming this allowance would be 32 hours per week. Absence from leave for carers would be financed by a ‘Familienpflegegeld (family care allowance = earnings replacement allowance) through taxation (not through Germany’s care insurance), analogue to Germany’s allowances for parents, and would include 36 months for each person requiring care. The emphasis of this model is on the ‘paralleling’ (congruence) of care and employment.
At the peak of the COVID crisis, the government took steps to facilitate family members’ caring roles for their (elderly) dependents. Among the changes, the duration of the carer’s grant, a wage compensation benefit for short-term absence from work to fulfil care obligations, and the accompanying leave provision were doubled from 10 to 20 workdays. In addition, the government made the unpaid family care leave more flexible. These measures were introduced as families reported difficulties finding care workers. It underlines not only the inherent familialism, but also that live-in and informal carers are seen as interchangeable by the government.
In addition to provisions on work-life balance for carers, German law (social law XI §19) also allows for the promotion of access to vocational training for carers who wish to return to working life once their care activity is completed.
- Recommendations for Family Carers Leave and Family Care Allowance (Empfehlungen zur Familienpflegezeit und zum Familenpflegegeld), Interim report of the German Independent Advisory Board, August 2022
- The 2021 Long-Term Care Report, Trends, challenges and opportunities in an ageing society, EC 2021
- First Report of the German Independent Advisory Board on Work-Care Reconciliation, June 2019
- UNECE Policy Brief on Ageing No. 22, September 2019
- The 2018 Ageing Report, Economic and Budgetary Projections for the EU Member States (2016-2070), EC, 2018
- ESPN Thematic Report on Challenges in Long-Term Care, Germany, EC, 2018
- The German LTC policy landscape, L. Frisina Doetter and H. Rothgang, SOCIUM, Research Centre on Inequality and Social Policy University of Bremen, 2017
- ESPN Thematic Report on work–life balance measures for persons of working age with dependent relatives, Germany, 2016
- Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability, EC, 2016
- Adequate social protection for long-term care needs in an ageing society, European Commission, 2014
Last Updated on March 2, 2023