Eurostat projects that by 2050 there will be nearly half a million centenarians in the EU. By 2100, the proportion of Europeans aged 80 or over is expected to rise from 6% to almost 15%.
In metropolitan areas, the number of older residents increased by 24% between 2001 and 2011. Some European cities and regions have already seen increases exceeding 50%.
Cities such as Barcelona, Amsterdam, Gothenburg, Greater Manchester, Nantes, Oslo, and Zaragoza already have higher-than-average proportions of senior citizens. In certain cases, forecasts indicate that by 2030, 30% of their population will be over 65.
The forthcoming EU long-term care strategy aims to address the challenges posed by low birth rates and high life expectancy, particularly concerning labour markets and healthcare systems. “Cities should be a part of the EU long-term care strategy,” asserts 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, recognising that ageing encompasses more than health—it’s about the experience of growing older.
Eurocities interviewed van Benthem to discuss our ageing societies, European care systems, and the pivotal role of cities.
Cities face significant challenges that will impact European long-term care systems. What should local leaders anticipate?
Demographic shifts are imminent. In Amsterdam—and other cities—the population over 65 has nearly doubled. Individuals with migrant backgrounds (EU mobile citizens, including newly arrived Roma, and third-country nationals) are projected to triple within 15 years.
These groups often encounter more problems integrating or learning the language, and they’re reluctant to trust public services. Compared to the general population, they often face poorer health conditions (particularly among first and second generations) and living circumstances.
We incorporate this scenario, along with the WHO Age–friendly Cities guide into our working group on urban ageing. Part of this framework draws from Manchester’s work, one of the founding cities of the Age-friendly city concept and a member of our team.
What challenges do older individuals currently 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 voice in addressing ageing challenges and long-term care solutions?
There are several reasons.
- Desire to age in place: People prefer to remain in their homes as they age. Both member states and the EU must support cities in creating conditions that facilitate this. Cities are best positioned institutionally to enable ageing in place. However, it’s challenging for cities to maintain quality of life and preserve social networks when vulnerable individuals must relocate due to the lack of age-friendly housing options.
- Preventative health strategies: Cities strive to keep residents healthy for as long as possible, thereby preventing the need for long-term care. Preventative strategies are more effective for individuals and the care system, especially with significant demographic changes on the horizon.
- Employment market challenges: Urban areas often face employment difficulties due to greater gender imbalances in the workforce and a growing care sector already experiencing staff shortages. Larger cities struggle more to find suitable personnel, as urban living is costlier, yet wages aren’t proportionally higher. In 10 to 20 years, there may not be enough care workers to meet demand. The shortage is particularly acute in long-term care, which is often viewed as less attractive compared to other care roles.
- Diverse populations: Cities receive the highest numbers of refugees, asylum seekers, and migrants, resulting in diverse backgrounds and vulnerabilities. This diversity complicates the tailoring of services to meet specific care needs while also supporting access to housing, employment, education, and social services.
Cities are at the forefront of demographic changes and long-term care strategies, even though the care sector lacks harmonisation.
Will cities require financial support from national governments or European institutions to address these future challenges? What do cities need, and how can they obtain 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.
Can the European Union provide assistance?
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 lessons from the COVID-19 pandemic should be incorporated into future care strategies?
Initially, older individuals were sometimes perceived as burdens due to their vulnerability to COVID-19. In the Netherlands and across Europe, there were alarming discussions, such as isolating older people in gated communities so the rest of society could continue without restrictions.
We’ve also reconsidered how care is delivered in nursing homes, where residents are more vulnerable. Questions arise: Is this the safest approach? Should we create smaller units or enhance hygiene practices? How can nursing homes provide quality care amid their specific challenges? Lifestyle factors—such as medical conditions, obesity, or smoking—also played crucial roles, as they increased the risk of severe COVID-19 outcomes.
An ageing population presents not only challenges but also inequalities. Addressing ageing-related inequalities may inadvertently create disparities in areas like gender, healthcare, employment, or youth. How can we tackle all these inequalities simultaneously?
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 mitigating 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.
