England & Wales, Global, Scotland Health and social care

Swift Read: Social care reform in the UK – can we learn from Germany?



Social care reforms have long been a key issue for local government, and now the strains have been exacerbated due to the pandemic. This briefing draws out lessons for the UK from an alternative, Germany’s long-term care insurance system, that could prove useful for shaping the future of the UK’s social care.

Briefing in full

Germany’s long-term care insurance (LTCI) explained

LTCI was introduced by the German government in 1995. It was foremost a response to Germany’s concern about its ageing population, which currently stands as the second oldest of all European Union nations. The reform was implemented in the midst of the significant economic upheaval that the reunification had brought a few years prior to 1995. LTCI was designed to reduce some of the existing social inequalities that hung over the previously divided country.

LTCI is administered by Germany’s health insurance providers and is mandatory, with citizens and their employers paying a monthly contribution that is proportionate to their wage.  It is built on the concept of universality and although most beneficiaries are above retirement age, assistance is available for anyone who requires it. It looks to provide a monthly care allowance to the benefactor, who then organises private care assistance with the funds. Due to the shortage of care workers, this is often a family member, with the amount given depending on the care level requirement. LTCI can also provide the insured person with a daily visit from a qualified carer, with the duration depending on the severity of their care requirements, or subsidised inpatient care. Latest figures indicate around two thirds of overall expenditure is cash benefits, which equates to 80% of all beneficiaries of the system.

LTCI has proved financially and politically stable over the last 25 years and stands as an excellent example of turning the requirement for long term care into a prerequisite of cohesive social protection. It also contributed to solving Germany’s previous struggle of providing residential care to those worse off, with its remit stretching to the provision of care home facilities for those unable to fund themselves.

Care homes and Covid-19 in Germany

Care homes in different countries have come under increased media scrutiny after they became a hotbed for Covid-19 cases internationally.  Germany has been a unique case study during this time, due to the varying success rate across the country of keeping Covid-19 out of residential homes. A recent study has found the risk of death in UK care homes to be 13 times higher than that in Germany. Although the total number of Covid-19 related deaths in German care homes remains relatively low compared to their European neighbours, it remains proportionately high to Germany’s overall death toll, mainly due to clusters and breakouts in several regions.

The responsibility of regulating and facilitating care homes in Germany was devolved to each region in 2006. In response to Covid-19, the federal government acted quickly in an attempt to reduce the impact in care homes across Germany, by announcing legislative changes to protect and support both care home users and nursing staff. The regional governments then exercised their autonomy to implement further restrictions. For example, Lower Saxony and Bavaria took almost immediate action in introducing full admission freezes to care homes.

The federal legislation also acknowledged Germany’s nursing staff shortage, allowing the recruitment of new personnel in care homes by lessening the qualification restrictions. This allowed some local municipalities, such as Gifhorn in Lower Saxony, Bamberg in Bavaria and the city of Hamburg, to enlist the help of soldiers with deliveries of food and essential resources.

The ability of state level governments to act quickly highlights the efficiency of Germany’s devolved autonomy. Most states decided to protect their residents by isolating care homes from outside visitors from the offset, with only Berlin offering one-hour visits in most homes. Devolved autonomy allows decisions to made quicker, which is vital in the midst of a pandemic and can be highly attributed to how some local municipalities in Germany have managed to avoid Covid-19 entering care homes entirely.

LTCI and local government in Germany

How care homes operate in Germany can be directly attributed to the LTCI model and explain the possible benefits of local government being at the forefront of policy reforms in the social care sector.

Before the introduction of LTCI, local governments were responsible for funding care home placements in their area with money that came out of their public purse. This is a prominent reason why local governments across Germany were instrumental in the introduction of the LTCI. At the time, local municipalities grouped together to advocate for policy reform after years of feeling the financial strain of receiving no federal support for these care costs. The introduction of the LTCI alleviated municipalities of these financial pressures and allowed them to redistribute their finances into other avenues.

Today, individual state laws determine how much each regional government invest in their long terms care facilities. With the daily costs covered by either LTCI or private payments, any designated funds are focused around investment costs of these long terms care facilities. Local governments also remain responsible for social security issues and can provide additional support in connection to long term care, such as social activities for seniors.

LTCI is not without its challenges and the Nuffield Trust examined the system in detail. Together with rising costs, one of the biggest problems in Germany is the shortage of a qualified workforce, which that underlines that however robust and efficient a health care system is on paper; it still requires a highly skilled and plentiful workforce to deliver its promises. Local governments and their affiliates have looked towards solutions, with one being increased training opportunities in the care sector for asylum seekers.

From the perspective of local government, moving the administration of long-term care to the federal level alleviated some of their financial pressures, which may be the most attractive point to those considering a similar reform within the UK.

Comment: what can the UK take away from this? a model for social reform?

There are many societal and practical reasons why a direct take-up of the LTCI model is unlikely to be implemented in the UK. Germany already operated under a successful single payer health care system, which is likely to have made implementation easier.

However, with many commentators saying for some time reform is needed, that reform needs to meet the cultural and societal norms for the UK. However, there are lessons from some of the principles behind the German system – fairness, transparency, consistency and stability that could be replicated. Whereas access to public health care services often varies dramatically across the UK, Germany seems to provide a more consistent level of service across the country, despite health care provisions being the remit of local and regional authorities.

The power of local government’s voice is strongest when they have existing autonomy in the subject matter, and local municipalities in the UK have long been involved in managing care provision and subsidising care home placements. As seen in the implementation of the German model – when the vision was not just for social care but also for sustainable communities, promoting independence and social inclusion – local government can act as important drivers for change and reform. If looking to bring forward reform, local government are most likely to find success if they act as a unified voice alongside stakeholders and health care providers within their area.

Any attempt at reform will need to be a long, sustained effort to bridge the gap in political difference at the national level. Social reform in Germany required agreement across the whole political spectrum, only reached after years of discussion. As of late, social care proposals in the UK have been raised around election times, when cooperation between political parties tends to be at it’s lowest. Social care reforms need to become something that stays on the agenda throughout each year and long term to achieve productive cross-party discussions.

If future population predictions are realised and the demand for long term care services starts to further outweigh the current supply, health care reform will soon become an even more prolific discussion within public circles.

Although the answer will not be a carbon copy of LTCI model, Germany’s reform should remain at the very least, an interesting case story for local government to review and learn from, creating the potential to influence and lead discussion, and to act as the catalyst for social care reform.