Long-term care and climate change
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As Care Initiative convener Professor Mary Daly noted in her introduction to this talk at Green Templeton College on 22 October 2025, care is part of the essential scaffolding of any society, but has long been both under-discussed and underfunded. While it now seems to be moving up the policy hierarchy in England and Wales, care’s history of neglect has left the sector – and as a result, society as a whole – poorly equipped to meet the urgent and complex challenges of the climate crisis. We still have, she acknowledged, very little idea of what a future-proof care system would look like.
Adelina Comas-Herrera’s talk outlined her work to address this situation by building on lessons from the Covid-19 pandemic and its impact on care systems around the world. She started by explaining her use of the term ‘long-term care’ as defined by the World Health Organisation in 2015 – a definition which highlights the “basic rights, fundamental freedoms and human dignity” of people receiving care. In practice, she explained, LTC is the product of an always complex and often messy combination of personal, local, national and global factors and systems.
Globally, most long-term care is informal and unpaid, especially in ‘traditional’ systems which depend heavily on family members – mostly women – alongside public sector or charity resources for the destitute and largely unregulated private care for the wealthy. While the dominance of informal LTC is coming under strain as a result of wider demographic, epidemiological, social and economic shifts, it in turn poses significant challenges for data collection and policy aimed at responding or improving resilience in the face of crises. This was starkly demonstrated during the Covid-19 pandemic, when, for example, the government of Chile was forced to develop emergency strategies to identify and provide PPE to unlicensed, unregulated care homes. Ms Comas-Herrera quoted a 2011 OECD report which concluded that the “piecemeal” development of long-term care policies had left LTC systems without a much-needed “comprehensive vision” of the future. “Muddling through”, the report argued, “is not enough.”
Ms Comas-Herrera’s work on the disproportionate impact of Covid-19 on care home residents around the world provides some lessons about structural challenges which undermined the preparedness and response of care systems. LTC is usually a low political priority, responsibility for it is often fragmentary, uncertain and poorly coordinated with healthcare, there is often weak regulatory oversight, and information systems are underdeveloped or non-existent. The last was illustrated by, for instance, the disastrous use by SAGE of data from cruise ships to model risk in care homes. At the same time, the human rights of care home residents are too often not recognized, there is widespread underinvestment in community-based LTC and its facilities, and care staff are poorly paid and work in poor conditions. The potential impact of this became clear during the Covid-19 pandemic where the precarity and lack of sick pay of LTC workers drove them to work while ill or work in multiple care settings, undermining attempts at infection control, for example.
In England, there were other, more specific problems and missed opportunities (Curry N, Oung C, Hemmings N, Comas-Herrera A and Byrd W (2023), Building a resilient social care system in England: What lessons can be learnt from Covid-19? ).
Overall, Covid-19 exacerbated but also highlighted existing problems in LTC, and led to some positives too: increased public, political and research interest, including international lesson sharing; improvements to information systems; examples of successful care coordination mechanisms; and innovations such as care ecosystems, smaller care homes, and new technology. These may help to inform strategies for adapting to climate change.
Like Covid-19, climate change disproportionately threatens older people and people with chronic illness and disabilities, who are more vulnerable to climate-related hazards such as extreme temperatures, wildfires, droughts, floods and climate-sensitive infectious diseases. Vulnerability, according to a framework developed by Wollschlaeger et al, is a function of three factors:
- Exposure to risk: for example, poor quality housing increases exposure to extreme temperatures, ground-floor housing increases exposure to flooding, the close proximity required by personal care increases exposure to infectious diseases
- Sensitivity: for example, older adults and people with disabilities have higher sensitivity to extreme temperatures
- The adaptive capacity of the system or population to cope with the effects of a crisis. An adaptive, resilient LTC system can reduce the vulnerability of people receiving care. However, ageism and ableism may cause emergency responses to deprioritize people with the greatest exposure and sensitivity.
It is essential that LTC services are resilient. This means, Ms Comas-Herrera explained, recognizing the importance of home and community-based care; an adequate, well-trained workforce; good-quality, well-designed, and well-located buildings; information systems covering formal and informal LTC, enabling real-time risk assessment and prioritisation in emergencies. Policy measures, regulation, and state investments in Denmark, Japan and France demonstrate how these can bring about higher standards in LTC facilities: in Japan, single-use rooms for care homes are designed with outside access which both improves quality of life and preparedness for emergencies such as earthquakes and floods. (Curry N, Oung C, Comas-Herrera A and Marczak J (2025), Building resilience in adult social care: Learning the lessons from other countries’ experiences of Covid-19.)
Drawing parallels between the effects of climate change and Covid-19 makes clear the need to address vulnerabilities in LTC on a systemic level, the speaker concluded, pointing to hopeful signs of change in the European Care Strategy and in more agile, rapid policy change in Japan, Korea and China. She emphasized the importance of tackling ageism and ableism, and of improving the status and working conditions of the LTC workforce, which will be key to preparedness, response and recovery, but which is currently subject to severe shortages in almost all developed countries. “In theory we had the pandemic to learn from,” she concluded, but “have LTC systems actually internalised those lessons?”
Questions raised the differential willingness of different countries to invest not only financial resources but time and effort into evaluating and designing better care systems. Japan, for example, has invested a lower percentage of GDP than many European countries, but has been more strategic in planning. Other questions covered the close relationship between care and housing policy, the need for different strategies for vulnerable people living at home, and examples of progress towards high-quality community-focused care in mixed-age developments in Oxfordshire and elsewhere. Inequalities in care-related needs and access to support were raised on a number of occasions in the discussion with the implications that addressing existing inequalities should be part of planning for the future. Ms Comas-Herrera raised the lack in the UK of public housing equivalents to private sheltered or cooperative housing for older people, in contrast to its inclusion in developments in places such as Barcelona and Singapore. She emphasized that there were good things happening in England at a local level; even while there are failures at the national level which means that basic scaffolding is missing. Audience members also asked about the evidence base for policy and financial prioritization, innovations in LTC payment models and funding (such as care insurance). An important message overall is that Covid-19 contained many lessons for planning for climate change.
