Eurostat predicts that there will be close to half a million centenarians in the EU by 2050.  By 2100, the European population aged 80 or more will increase from 6 to almost 15%.

In metropolitan areas, the number of older people increased by 24% between 2001 and 2011. In some European cities and regions, increases of over 50% are already visible. 

Barcelona, Amsterdam, Gothenburg, Great Manchester, Nantes, Oslo, and Zaragoza already face senior citizens rates higher than the average. In some cases, predictions show that 30% of their inhabitants will be older than 65 by 2030.

The upcoming EU long term care strategy will cover the challenges that low birth rates and high life expectancy entail, especially to our labour markets and healthcare systems. And “cities should be a part of the EU long term care strategy,” says Tom van Benthem, Strategic Policy Advisor at Amsterdam City Council and Chair of Eurocities Working Group on Urban Ageing.

“It’s also not just about long term care,” van Benthem says, “but the entire care process, which usually takes place in cities.” The group’s approach is intersectional, given that ageing, maintains van Benthem, is not only a matter of health but also about living while becoming older. 

Eurocities interviewed van Benthem about our ageing societies, European care systems, and cities’ role. 

Cities have fundamental challenges ahead that will impact European long-term care systems. What’s the situation local leaders must be ready for?
The demographic change is coming. In Amsterdam –and other cities– the number of people over 65 has already almost doubled. People with a migrant background (EU mobile citizens, including newly-arrived Roma, and third-country nationals) will triple in 15 years.

They usually have more problems integrating or learning the language, and they’re reluctant to trust public services. Compared to the average population, these profiles often face worse health conditions (at least for the first and second generations) and living circumstances.

We use this scenario plus the WHO Age–friendly Cities guide at the working group for urban ageing. Part of this was based on Manchester’s work, one of the founding cities of the Age-friendly city concept and a member of our team.

What’s the current situation the elderly face? 

People say that the demographic change will happen in the countryside because youth will move to cities and older people will stay behind. But we’ve done some research with ESPON, a European project, showing that ageing is also a problem with an urban dimension.  

People want to live longer at home, which has its challenges in cities with the housing stock available. The care system in cities should respond to an unhealthier population in general  (though this varies over Europe) — than in the countryside.

At the same time, ageing should be an inclusive process in which older people must not be considered a burden. However, there are all kinds of prejudice about people getting older. It’s said the older people take the bigger houses and amenities that should be for the youth, that they cost money and don’t deliver money.

In this sense, we combat ageism and work on all this in our working group, where the scene is diverse and exciting. 

Why should cities have a say on ageing challenges and long term care solutions? 

There are several reasons.  

• People want to live longer at home, and both member states and the European Union need to help cities create the right conditions to make this possible. Cities are at the adequate institutional level to make this possible and are the ones realising living longer at home. It’s more challenging for cities to maintain quality of life and preserve the elderly’s social network when having to relocate those with vulnerable physical circumstances due to the lack of possibilities to make the housing stock all age-friendly. 
• Cities work to keep our citizens as healthy as long as possible and thus prevent our citizens from getting into the long term care system. A preventive strategy is more effective for the people involved and for the care system as a whole., especially with the biggest consequences of the demographic change still ahead of us.  
• Additionally, cities often face more difficulties in the employment market due to a greater gender disbalance in the workforce and the growing care sector that faces already a shortage of staff. The bigger the city, the bigger the problem is finding the right team since urban living is more expensive than the countryside, while wages are usually not higher. In 10 or 20 years, there won’t be enough people working in the care sector to deal with the demographic change. The shortage of carers is even worse in the long-term care sector as it is seen as the least attractive one compared with other roles in the care field. 
• Cities are receiving the highest number of refugees, asylum seekers and migrants and face the most significant mix of diverse backgrounds and vulnerabilities. This challenges tailoring services for catering to their specific care needs while at the same time supporting them to access other relevant services (e.g. housing, access to the labour market, training and education, social services, etc.) 

Cities are at the core of the demographic change and the long term care strategy, even though the care sector isn’t harmonised.

Do you believe cities will need financial support from the national government or European institutions to face these future challenges? What do cities need, and what’s the best way to get that support?

In the Netherlands, we have extensive discussions about how we’ll be able to afford the care sector in 10 years. However, the demographic change is so significant that we may simply not be able to afford it. By that date, we need one and a half times the amount of people working at the moment, let alone the money.  

Although we’re talking about a very slow changing process, policies should adapt now. However, since health care is a fundamental human right, it’s problematic to change how to deliver this change and make very tough decisions about what kind of care should be delivered to whom, either as a city, country, or the European Union.  

Getting funds is essential, but it’s urgent to determine a specific role for cities. Informal carers already play a big part that differs per country and city, but the general rule of thumb is that the less formalised care, the bigger the informal sector is. Here cultural differences between countries also play a significant role. 

Some form of harmonising all European care systems would be essential before claiming money from the EU, but that wouldn’t be very pleasant. We have a costly healthcare system; if Hungary (for example) did the same, it would entail tripling their budget, maybe quadrupling it. The EU could, of course, help out much better in helping in the transition all care sectors and societies have to go through to adapt to the demographic change.

In that sense, it’s encouraging that the European Commission now has a commissioner on demographic change, which we already had a conversation about while offering the results of the ESPON project to her. We talked about a silver deal being necessary next to the Green Deal already made on the European level, due to the scale of the change coming our way.

So can the European Union help? 

I would not expect concrete actions from the European Union in the care sector but rather guidelines to make it the best sector possible from a European point of view. This entails dealing with technology, employment, innovation, and procurement, those fields where the EU has the competencies. 

For example, the EU can help cities with innovation and its technological scaling up. Many innovative approaches in the care sector often deal with the technical side but not the social one. For example, you can now have cameras in your house to alert somebody if you fall and stay still. But the technology sector only develops the cameras. They don’t organise that care services know how their services should change to make the best out of the technology with an actual efficiency possible instead of adding more staff to work with the new technology.

What takeaways do you have from the COVID19 pandemic to incorporate into future care strategies? 

First of all, older people were sometimes seen as a burden because of their vulnerability to COVID. At the national level in the Netherlands and all over Europe, there were sometimes shocking discussions, such as putting the older people in a gated community, for example, so the rest of society could keep on living without restrictions.  

We’ve also learned to rethink how we deliver care in nursing homes, where people are more vulnerable. ‘Is this the safest way to do this? Should we make smaller units or pay more attention to hygiene?’ How can we make sure the nursing homes can deliver the quality of care needed with the challenges that they specifically face? And, in cases of people having some condition whether it be medical, lifestyle condition, overweight or smoking, lifestyle played a crucial role. They had the risk of more severe consequences of COVID. 

An ageing population triggers not only challenges but also inequalities. The reduction of ageing inequalities may generate others in fields such as gender, the health sector, employment or youth. How can we tackle all those inequalities at the same time? 

That’s the most exciting addition to the WHO age-friendly city approach. Cities can evaluate the whole system methodology through a strength and weakness analysis every few years. Then you pick a few domains based on your analysis and identify the biggest challenges for the next three years. After that, there is a research process, and in year five, you start again with reevaluating attending at ‘Where are we now? What kind of achievements did we reach, and where did we fail?’ What’s difficult is that, as the city, you don’t control the whole system.  

Inequalities are an effect of life, but our job as a city is to prevent those equalities from getting more prominent (and COVID has undoubtedly done so). Reducing inequality is possible but depends on the political philosophy in your city. We‘re here to help the people most deprived of the proper care and housing. I’m not optimistic that we will ever make those inequalities disappear, although our work should never stop trying. 

In your opinion, is there any city that stands out in preventing the consequences of urban ageing? 

All the cities in the working group are doing great, and we all do it in different ways. The beauty of the Eurocities network is that you can learn from others. Some are tackling things with mobility, others with public spaces, and others focusing on the social part.  

Since we all use the same framework, our work can be compared, not for what we did, but by relating to what ESPON made. Out of the eight cities involved in that research, seven are part of the working group urban ageing. It was a great way to share our knowledge, not just between us but also in Europe. 

Eurocities members discussed this and other challenges of the care system at the Eurocites Social Affairs Forum hosted by Barcelona in May 2022. 

To dig into long term care and how to adapt to the challenges, the Urban ageing working group will gather in Oslo from 8-10 June. The event will analyse the ideas that the host city is implementing in age-friendly cities, which made it the winner of national awards. And Eurocities will present some preliminary results from the survey on long term care. A WHO representative will also share with members the most recent initiatives of the organisation regarding age-friendly cities.