The biggest difference between countries is who is responsible for looking after older people and who pays for that care.

Some countries treat long-term care as a public responsibility, funded largely through taxation or social insurance. Others expect families to provide more support, with government assistance available only in certain circumstances.

The UK sits somewhere between these approaches: local authorities support people who meet eligibility criteria, but many older people must contribute towards their own care.

The OECD's 2025 analysis of 29 countries identifies substantial differences in access to care, public funding, family support and quality standards.

1. Six different approaches to pensioner care

🇬🇧 United Kingdom - means-tested support

In England, care is generally organised through local authorities and private or charitable providers.

People with eligible care needs may receive council-funded support.
Financial assessments determine how much someone must contribute.
People with substantial assets may have to pay for their own residential care.
Support at home is available, but access and eligibility vary.

The central issue: Older people can face significant personal costs, particularly when they need residential care.

🇩🇪 Germany - long-term care insurance

Germany operates a compulsory long-term care insurance system.

Most people are covered through statutory or private insurance arrangements.
Benefits can help pay for care at home or in a residential facility.
People can receive cash benefits to support family-provided care.
Insurance does not necessarily cover the full cost, so individuals may still pay substantial amounts.

The central feature: Care is treated as a social insurance responsibility, but families and individuals still contribute.

🇸🇪 Sweden - publicly funded care

Sweden relies heavily on municipal services and public funding.

Older people can receive support at home or in residential care.
Municipalities assess care needs and organise services.
Fees are generally regulated, with protections linked to income.
Family members may provide support, but the system places substantial responsibility on public services.

The central feature: Public authorities play a major role in arranging and funding care, although eligibility and local provision matter.

🇯🇵 Japan - long-term care insurance

Japan introduced a national long-term care insurance system in 2000.

Older people can qualify for services following a care-needs assessment.
Services include home help, day care and residential care.
Public insurance covers a substantial share of eligible costs.
Users generally pay a contribution, with the percentage depending on their circumstances.

The central feature: A national insurance system helps people obtain formal care rather than relying entirely on relatives.

🇺🇸 United States - a mixture of private and public provision

The US has a more fragmented system.

Medicare generally does not cover long-term custodial care.
Medicaid can cover qualifying long-term care for people who meet financial and other eligibility requirements.
Private insurance and personal savings may help fund care.
Family members often provide unpaid support.

The central feature: Access to care depends heavily on financial circumstances, insurance coverage and state-level arrangements.

🇨🇳 China - family care alongside expanding public services

China has traditionally relied heavily on families to care for older relatives.

Adult children often play a major role in supporting ageing parents.
Public and private residential care facilities are available.
Community-based and home-care services are expanding.
Access to services and financial support varies significantly between regions and households.

The central feature: Family responsibility remains important, while formal care provision is developing.

2. Who pays for care?

One of the most useful comparisons is how much of the cost is covered by public support.

The OECD's 2024 analysis found that public support varies widely, even among wealthy countries. For older people with severe care needs, some countries cover most of the cost, while others leave individuals facing substantial bills.

These are broad descriptions; the actual amount paid depends on care needs, income, assets and local rules.

3. How much do countries spend on care?

Public spending on long-term care differs substantially.

The OECD's Health at a Glance 2025 reports that countries such as the Netherlands and Nordic countries devote a relatively large share of GDP to long-term care, while several countries spend considerably less and rely more heavily on informal family support.

This matters because lower public spending does not necessarily mean older people need less care.

It may mean that more care is being provided by unpaid family members, that fewer people receive formal services, or that care needs are going unmet.

4. What about loneliness and companionship?

Care is not only about washing, dressing, medication and meals.

It is also about whether an older person has regular human contact and opportunities to participate in society.

Countries differ in how they support this:

Some provide organised community activities and day-care services.
Some have extensive home-care services that bring workers into people's homes.
Some rely heavily on relatives and neighbours.
Some offer residential facilities with communal activities and social programmes.

However, formal care does not automatically eliminate loneliness. An older person can receive excellent physical care and still lack meaningful companionship.

The OECD identifies availability of formal services and support for informal carers as important dimensions of long-term care systems.

5. What can we learn from these differences?

There are three broad approaches to the problem of ageing and care.

In practice, most countries combine elements of all three.

The important questions are whether people can access care when they need it, whether they can afford it, and whether family carers receive sufficient support.

6. The question for Britain

Given our discussion of care home fees, care worker wages and lonely pensioners, the central issue is this:

Should Britain rely primarily on individuals and their families to fund and provide care, or should it accept greater collective responsibility for ensuring that older people receive care and companionship?

International comparisons show that countries organise this responsibility in different ways. They also show that public funding, family support and personal contributions can be combined in several ways.

No system removes every problem. The real differences lie in how the costs and responsibilities are shared, and how effectively older people receive the support they need.