Following the submission of an initial report in July 2005 on the evolution of illness related to old age and estimations of the number of accommodations available for the dependent elderly, the French minister in charge of elderly affairs asked the Strategic Analysis Centre to further consider how to provide and finance the care of dependent persons until 2025. Relying on a single quantitative scenario, the report proposes a global strategy turning on several key principles: a preference for in-home care and supplying treatment in a welcoming environment, reliance on technological and social innovation, the qualitative improvement of establishments housing the most dependent persons and the use of new regulatory tools in order to promote performance and a better territorial distribution.
Creating a Free Choice Scenario
For economic and social reasons, the French government is willing to give the elderly a freedom of choice regarding
healthcare and accommodations. Such a policy requires the simultaneous and complementary development of services
designed to care for the elderly in their own homes as well as access to retirement homes. A policy to that end has been launched in the framework of the first “Ageing and Solidarity” plan, which includes a significant attempt to increase availability of all the types of care for the dependent elderly. Efficient investment implies an extensive
study of a balanced scenario including the development of a global offer covering all types of home and institutional
care. In this respect, the minister in charge of elderly affairs asked the Strategic Analysis Centre to
- establish the number of additional rooms in homes for dependant elderly (EHPAD1) needed from 2010-2015 and an estimation for the year 2025,
- anticipate the number of home care assistants required in these two time horizons,
- analyse the geographical distribution and propose guidelines for better EHPAD accommodations,
- examine issues related to financing and ensuring an even geographical distribution.
A first report was elaborated in 2005 with quantitative forecasts including various scenarios of home and institutional care capacities. The second report, published in June 2006, proposes a single scenario, including an estimation of the requested workforce, taking societal and financial aspects into account.
Developing the Scenarios and Political Options
Studying the ageing society implies taking different variables into account such as demography, healthcare improvement, the development of people’s behaviour and also various political options.
In addition to the Strategic Analysis Centre’s staff, the National Institute of Economic Statistics (INSEE), the National Solidarity Fund for Autonomy (CNSA), the health ministry’s department of statistics (DREES) and other central administration resources were solicited for this exercise.
First Report: an Extensive Quantitative Analysis
The first report aimed at exploring possible scenarios for the development of the number of accommodations available for the dependent elderly (EHPAD) for the years 2010, 2015 and 2025. This exercise required the following sequence of calculations:
- elderly population growth,
- the development of the prevalence of dependency within this population,
- the consequences in terms of demand for home and institutional care,
- achievable supply of accommodations and workforce in this sector.
As a result, five scenarios were adopted to reflect different balances between home and institutional care. In addition, each of these scenarios was developed based on two different dependency rates and for three time-horizons.
In order to calculate the respective workforces that would be required for home and institutional care in each case, the team also had to envisage different levels of assistance.
Second Report: Further Exploration of a Single Scenario and Elaboration of Recommendations
The second report was elaborated by a group of 60 experts from various local and national institutions, universities, hospitals and associations. Their work also relied on the results of an ethnological study carried out in three different homes for dependent elderly.
First, the group conducted an in-depth analysis of a single scenario by distinguishing different levels of dependency and types of skills required for health care and assistance. The results were used to predict the development of the labour market in this sector until 2025.
Workshops were then organised in order to arrive at recommendations on how to conceive future homes for dependent elderly and optimise the financing of national and local schemes addressing the ageing population.
More Intensive Institutional
Care for the Most Dependent
Demographic development is reasonably predictable. The following chart gives a projection of the number of dependent elderly aged 75 and older:
x 1000
| 2005 | 2010 | 2015 | 2025 | 2030 | |
| High projection | 682 | 741 | 808 | 920 | 1 017 |
| Low projection | 657 | 691 | 732 | 805 | 855 |
Source: Insee Destinie, projections Drees-Insee
The first report established five possible scenarios in order to capture the broadest possible range of impacts of population ageing on the caring system:
- Scenario 1 assumed that the current distribution between home care and institutional care would remain constant, thus predicting an increased need for places in rest homes and other care institutions.
- Scenario 2 and 3 planned for an increased recourse to home care: for all elderly, irrespective of the level of dependency prevalence (sc. 2), and for all elderly with the exception of the most dependent (sc. 3). These two scenarios led to a reduced need for specialised accommodations.
- Scenarios 4 and 5 envisaged an increasing recourse to institutional care: for all elderly in scenario 4; for the most dependent only in scenario 5. Scenarios 2 and 4 were abandoned as too extreme, whereas scenario 3 was chosen as the most efficient and socially satisfactory framework for the future development of the French elderly care scheme.
Forecasts on Needs for Accom- modations and Human Resources
In this scenario, the rate of the most dependent elderly benefiting from institutional care is expected to reach 67% by 2010 and then be stabilised. Simultaneously, the rate of less dependent elderly who benefit from home care is expected to rise progressively.
This scenario thus assumes two consequences in terms of accommodations and human resources:
- intensified care in specialised institutions and
- more dense and diversified types of home care.
Needs for Specialised Facilities
Consequently, with the projected institutional care rates, the report recommends increasing the number of places in specialised facilities up to 680 000 in 2010 – among them 610 000 for the elderly aged 75 and older – and to stabilise this number after 2010.
The following targets for the distribution of places for the 75+ population show that, even within the institutional care solution, priority is given to temporary, flexible care solutions.
| 2010 | 2015 | 2025 | |
| Little medicalised accommodations | 90 000 | 90 000 | 90 000 |
| EHPAD | 420 000 | 402 000 | 392 000 |
| Long-stay hospital accommodations | 60 000 | 60 000 | 60 000 |
| Temporary accommoda-
tions |
40 000 | 58 000 | 68 000 |
| Total | 610 000 | 610 000 | 610 000 |
Reaching these targets implies various actions: a sustained effort to create new places by 2010, but also withdrawing licences from obsolete structures and converting some nonspecialised accommodations into EHPAD.
Increased Need for Institutional and Home Care Personnel
The population in specialised institutions can thus be expected to increase by 2010 and be comparatively more dependent than it currently is. These two trends justify the need for a drastic increase in personnel in these institutions. The report team has chosen to rely on two projections in terms of supervision rates (number of staff per 100 residents):
- a low projection: from 57.4 in 2003 to 75.7 in 2025,
- a high projection: from 57.4 in 2003 to 81.4 in 2025.
As regards home care, the growing share of elderly people who would benefit from this solution implies that the need for staff in the medical, paramedical and social home care sector will also clearly increase.
In the current situation, each dependent person benefits from an average assistance volume of 150 hours per month (the calculation is based on the French dependence allocation distribution). The report team suggests increasing this average volume by 55% by 2025. It must be noted that these projections are based on the assumption that the help currently received by the elderly from their relatives will remain constant, which is all but certain.
Need for institutional and home care staff 2005-2025:
| 2005 | 2010 | 2015 | 2025 | |
| Low institutional care projection | ||||
| Institut.-care staff | 233 400 | 279 900 | 296 700 | 315 500 |
| Home-care staff | 375 600 | 415 500 | 501 400 | 739 500 |
| Total | 608 900 | 695 400 | 798 100 | 1 055 000 |
| High institutional care projection | ||||
| Institut.-care staff | 233 400 | 290 000 | 313 800 | 333 000 |
| Home-care staff | 375 600 | 415 500 | 501 400 | 739 500 |
| Total | 608 900 | 705 500 | 815 200 | 1 072 500 |
In terms of job creation, in total, 342 000 to 360 000 positions will be available in this sector over the next ten years, which represents 4,6% of all available positions in the French economy (this includes net creations and replacements after retirement). Net job creation in the elderly care sector alone can be expected to account for 11% of new jobs in France over the same period.
Guidelines for Better EHPAD Accommodations:
Diversification and Territorial Distribution
The Social Background to the Free Choice Scenario
The target population (aged 85+, 2015-2020) forms a very different social group from today’s elderly. The current babyboomers are more individualistic; they have developed an identity of active (and exigent) consumers, are geographically and professionally mobile and are used to actively deciding upon matters affecting the course of their lives. These features will have to be taken into account in drawing up tomorrow’s care system and the care accommodations it is to provide. This system and the related accommodations will have to – answer a broad diversity of needs and thus provide an equally broad diversity of adapted services and – take into account a diversity of life territories, values and cultures, and thus be equitably distributed geographically to allow the elderly to maintain their life habits.
An EHPAD should ultimately provide its residents with all needed services and assistance, while being a true living place in the full sense of the word. This includes several objectives, which have some technical impacts.
Supporting a Project for Life and Maintaining Social Life
- Project for life: EHPAD should be conceived so as to allow the residents to further develop and not to simply “end their lives”. This includes preserving their freedom in terms of time and space organisation, favouring creativity and encouraging autonomy.
- Social life: Residents should be encouraged and supported in the perpetuation of their social life through the preservation of family links. This means that exchanges between the residents and the exterior should be encouraged
(vicinity, city, village etc.)
EHPAD’s Projected Features to Answer these Needs
Localisation elements
- The geographical distribution of EHPADs should allow residents to remain in the vicinity of their former place of residence in order to facilitate preserving their family and social links.
- EHPAD’s localisation should ensure a social openness: opportunities for the residents to leave the facility and have access to a city or village.
Technical features
- Space organization in EHPAD should provide the residents with private, intimate spaces as well as with community spaces.
- Specific features of the accommodations should allow a customisation of individual living quarters (mobile walls, Internet connections etc.)
Organisational features
- Security and health norms should be intelligently adapted in order to provide the residents with all necessary services and care while infringing as little as possible upon their liberty.
- A provision of diversified services should allow the residents to be provided with any needed service (medical and non-medical).
Dual Policy Challenge:
Services Synergy & Balanced Geographical Distribution
The overall financing need over the 2006-2025 period is estimated at a total between 14-29 billion €. This would represent around 1.1% of GDP in 2010, 1.2% in 2015 and 1.5% in 2025. This financial effort is considered not to be insurmountable, on two conditions: that savings are made in other domains in order to alleviate the burden on the social security resources and that an efficient redistribution is conducted between the hospital sector and the dedicated elderly care system.
Ensuring Sufficient Care Personnel
Professional Staff
A specific effort will have to be made to make medical, paramedical and social professions in the elderly care sector more attractive than they are today and to ensure an efficient balance between childcare, hospital care and elderly care staff.
Support to Involved Relatives
Several European states provide financial and fiscal incentives to relatives who reduce their working hours or even suspend their own careers to take care of a parent. In particular, France could follow the example of the German system where the social security system comes up for the social security contributions of people who have stopped working to take care of an elderly person.
Rethinking Programming and Efficiency
Proposing diversified care services while maintaining a fair geographical and cost distribution implies two levels of action:
- Evaluating and programming at the national level in order to take inventory of the global needs and appreciate the relative financial burdens that have to be assumed locally. The team suggests that all involved actors adopt a unified evaluation methodology, which means rethinking the whole current social aid system. The state would have to shoulder a share of necessary start-up investments to ensure that the restructuring is initiated not only in the wealthier regions but rather equitably throughout the whole territory
- Transferring a larger share of responsibilities (if not all of them) for elderly care to the French départements (sub-regional administrative level). As local administrations, they would be in a better position to adapt the services offered to local needs and specificities. In this respect, the report team suggests that a better synergy between all types of services be organized, for instance, by allowing EHPADs to manage, through new regulatory rules, the coordination between private and public, medical, paramedical and social services.
The Follow-up
The report was made public in late June 2006 at the same time as the government’s ‘Solidarité Grand Age’ plan, which it heavily draws upon. The plan concerns the 2007-2012 period and is projected to cost the French social security system 2.7 billion €. While most of sector’s representatives have overall welcomed this plan, the related financial allocation was viewed as underestimated.
| Authors: | Hugo Thenint – Louis Lengrand et Associés (LL&A) hugo@ll-a.fr | ||||
| Sponsors: | French minister of social security, elderly, disability and family affairs | ||||
| Type: | National – but includes case studies on other countries | ||||
| Organizer: | The Strategic Analysis Centre (former Commissariat au plan) | ||||
| Duration: | 2005-2006 | ||||
| Budget: | n.a. | ||||
| Time Horizon: | 2025 | ||||
| Date of Brief: | April 2008 | ||||
Download: EFMN Brief No. 139_ Elderly Care in France
Sources and References
Strategic analysis centre: http://www.strategie.gouv.fr/article.php3?id_article=277
La documentation française (first report): http://www.ladocumentationfrancaise.fr/rapports-publics/054000490/index.shtml