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Building a shared priority
Public thematic report
Abstract and annexe 7
November 2021
The prevention of loss of independence has been widely discussed for ten years in
parliamentary proceedings
, by researchers and specialists from various backgrounds, and in
administrative reports. The analyses often cover the same ground, in particular in their
emphasis of the importance of the issue of predictable ageing among the general public, but
also their desire to live independently at home for as long as possible.
However, prevention stakeholders are disparate, and their work often overlaps. This
situation markedly reduces the effectiveness of this policy, and creates a form of inertia among
stakeholders. The purpose of this report is to identify and analyse problem areas, then to
outline approaches that may remedy this lack of effectiveness.
The current situation: people live longer in France than elsewhere,
but not necessarily in better health
The Court’s investigation covers the stage prior to the loss of independence; that is,
prevention. In medico-social terms, the selected target is individuals who retain independence
in terms of essential daily activities (GIR 6)
or merely require occasional assistance (GIR 5).
Comparisons were made with seven other countries, and the Court was also assisted by a
committee of experts.
The French population is ageing, in common with OECD countries in general, and this
ageing will accelerate once the many “baby boom” social sectors reach the age at which loss
of independence most often occurs, i.e. over 85 years old. France had 100 centenarians in
1900, and 1,120 in 1970; the number is currently 26,300 and will be approaching 200,000 by
Although the likelihood of loss of independence increases statistically with age (Chart 1),
it is not an inevitable consequence of ageing. Consequently, its prevention is not only
given the anticipated demographic development
but also feasible.
One such analysis is the information report by Mr Bernard Bonne and Ms Michelle Meunier for the Senate Social
Affairs Committee on the prevention of loss of independence (March 2021) which proposes to enshrine home
support in positive law, provide for preventative visits at age 75 and unify tools for assessing the situation of
The degrees of loss of independence are classified into six groups with equivalent resources (GIRs) addressing
different assistance needs. Only GIR 1 to 4 result in an entitlement to APA. Individuals covered by GIR 5 (requires
one-off assistance with washing, preparing meals and cleaning) or 6 (still independent for essential daily activities)
are not entitled to APA, but may ask for help from their pension fund.
Rate of loss of independence between 2007 and 2014 by gender
Source: Court of Accounts, based on Drees data
Note to reader: the percentage of Health in Daily Life (VQS) scores > 40
is 12% among women aged
75-79 in 2007, against 10% in 2014.
In its current state, however, the French prevention system does not demonstrate an
ability to face the problems to come. It needs to be improved.
A life expectancy of 65 may well be higher in France than in other European countries.
On the other hand, the healthy years of life represent only half of the desired time, while many
other countries
eleven in Europe
do better.
The “VQS score” is calculated to produce a single figure summarising the difficulties encountered by the elderly
(physical, sensory, cognitive functional limitation, chronic disease). An elderly person reporting major limitations
across many activities will thus have a high VQS score. A person with a VQS score greater than 40 is considered
to have lost their independence (source: Mr Brunel
A. Carrère, “Incapacities and loss of independence among
the elderly in France: a positive change between 2007 and 2
Cahiers de la Drees
no. 13, March 2017).
Life expectancy of 65 in 2019
Source: Court of Accounts, based on Drees data
The Court calculated that a one-year increase in disability-free life expectancy (EVSI)
would save health insurers an amount of around €
1.5 billion4. In addition to the individual and
collective benefit to the people concerned, these financial issues provide full justification for
public intervention in preventing loss of independence.
The disparate nature of stakeholders means that a policy generally
accepted in principle fails to deliver practical benefits
There are a large number of stakeholders involved, in one form or another, in managing
the prevention of loss of independence (departmental councils, pension funds, regional health
agencies, primary health insurance funds, the
Agence nationale de l’habitat
housing agency,
municipalities and inter-municipal cooperation agencies, regional councils, social landlords,
mutual bodies, associations, etc.). It is true that the restructuring process began in 2015 with
the creati
on (by means of the “ASV” Adaptation of Society to Ageing law of 28 December
, of funders’ conferences, chaired by the presidents of departmental councils.
Using the Pandora health expenditure projection, the Court estimated a gain of one year of life expectancy without
disability over the 2021-2031 period. In the absence of data on average medico-social expenditure by age, this
estimate does not take into account the savings in terms of APA, accommodation or day care linked to a one-year
improvement in EVSI. It is therefore underestimated.
Law no. 2015-1776 of 28 December 2015 relating to the adaptation of society to ageing.
Meanwhile, a social initiative by pension funds has established an “inter
scheme” association
. However, change within the system as a whole is still multifarious, administratively
complex and disorderly. Furthermore, there is no obvious way of estimating the value of
expenditure on the prevention of loss of independence. The Court estimate
s it at nearly €
billion per year, including nearly €
460 million for “technical aids” (chairs, walking frames,
sticks, etc.) for health insurance and nearly €
300 million for the social work of the CNAV fund.
Estimated expenditure on preventing loss of independence
(2019 or 2020, depending on the source)
Funders’ conference
CNAV social measures
Agirc-Arrco social action
MSA social action
CNRACL social action
Social action by State civil service
Housing adaptation including tax credits
Health insurance technical assistance
Source: Court of Accounts calculations based on data from government organisations
and social security bodies
Whole sections of prevention policy still fall outside the cooperative process. This means
that users are often faced with a proliferation of contacts, and the very real risk of
discouragement. For example, the mutual recognition of GIR classifications between pension
funds and departments, as provided for by the ASV law, has still not come into effect, resulting
in redundant assessments and the shuttling of applicants from one organisation to another. In
another example, the health insurance and pension funds have developed two different
hospital discharge systems.
At a basic level, however, there are areas of concordance.
This is true, for example, regarding individual behaviours to be encouraged or nurtured.
It is commonly believed that the pivotal times in life for preventively changing habits are (1)
around 40-45 years of age and (2) at the time of retirement (for example, for physical exercise).
There is also a need to promote sufficient physical activity for the elderly, which should be
adjusted according to their condition. The failure to implement the medical prescription for
physical activity tailored to patients suffering from chronic diseases, which was approved back
in 2017 but has not met with the expected success, underlines the scale of the work yet to be
done in this area.
There is also a consensus over the urgent need to prevent falls in the elderly, accounting
for more than 10,000 deaths in people over the age of 65 each year. France has a higher
incidence of accidents involving damage to the tip of the femur than the United Kingdom, the
Netherlands or Denmark. According to the work carried out by the Toulouse University Hospital
Since 2011, the inter-scheme pension funds process has taken the form of coordinated activity between the CNAV,
the agricultural social mutual body (MSA) and the social scheme for independents (RSI) with the aim of providing
shared information to retirees and organising collective prevention actions and workshops.
Excluding “housing and living environment” expenditure shown in the “Housing adaptation” line.
Supplementary pension scheme for employees in agriculture, commerce, industry and services.
in collaboration with the Court, the additional health expenditure associated with the care of
patients suffering f
alls is in excess of €
900 M in the year following the accident alone. It is
possible to take measures aimed at prevention, in particular by limiting medical9 iatrogenesis,
by making adaptations to the home and by modifying physical activities appropriately, but
France neglects this field of action; indeed, it no longer has any public health goal in this area
and no centralised monitoring mechanism (recommendation 2).
The (also generally accepted) goal of promoting care at home by means of adapted
housing faces obstructions in the form of several factors involving inertia or inefficiency: too
much complexity for potential beneficiaries, lack of monitoring (neither the need for nor the
number of adapted homes is known), and fragmentary technical skills among the agents
responsible for home diagnoses (recommendation 1).
Lastly, there has only been the faintest glimmer of rising awareness in two areas of
prevention: the fight against isolation among the elderly (an aggravating factor in loss of
independence), an
d initiatives to raise health professionals’ awareness of screening for
(recommendation 3).
Improved structure for prevention
Prevention services are currently disparate and provide unequal levels of support. They
need to be rethought. The Court recommends creating a tiered range of services, comprising
three levels:
- at the first level: general information accessible through communication campaigns for the
general public, improved coordination between national information and information from
local authorities, and the creation of a telephone information system;
at the second level: a policy of “moving towards”
, combined with the possibility of a home
consultation visit carried out by professionals trained in prevention issues, upon request;
- a third level, reserved for the most socially vulnerable or isolated people, with assistance
plans implemented through social measures by pension funds, which must, for this
purpose, be rethought for greater consistency. This point is also the subject of a
recommendation (no. 4).
If the impact of this policy is to be improved, it will require clarification of the roles of local
and national stakeholders. The steering process should be improved to ensure the integration
of prevention into the fundamental goals of the independence branch. The proposal is
therefore to:
Iatrogenesis is defined as harmful impacts on health resulting from medical intervention (diagnostic errors,
inappropriate prescriptions, complications from a therapeutic procedure) or from the use of a health product. It is
particularly worth noting the link between the use of psychotropic drugs and the occurrence of falls. Researchers
also estimate that around 400,000 cases of iatrogenic dependency, acquired during a hospital stay, could be
prevented each year in people aged 75 and over.
in other words, the ability to carry out ordinary everyday activities.
This concept, initially devised as a solution in the fight against poverty, is used in many social policies to
encourage professionals to reach out to users to combat failure to access services, care, etc.
- strengthen the department in its leadership role, responsible for the prevention policy in its
own geographical area, in close partnership in particular with the regional health agency
and Carsat (recommendation 4);
- at national level, allow the CNSA to adjust the credits it pays to the local departments, with
the goal of greater geographical equity, and equip it with sufficient resources to enable it
to fulfil its role of national implementer of the policy for preventing loss of independence
(recommendations 5 and 6).
Summary of recommendations
Increase and monitor work to adapt housing while simplifying assistance and standardising
(Ministry of Social Support and Health, Ministry of Housing)
Define an ambitious public health goal of reducing the incidence of falls and induced deaths
by providing regional health agencies with the tools to enable them to implement the
measures identified to achieve this goal, including a systematic statistical register of falls
(Ministry of Social Support and Health)
Encourage healthcare professionals to modify their practices (detecting signs of weakness,
prescribing appropriate physical activity, re-examining the benefit of medications, etc.) by
means of financial incentives
(Ministry of Social Support and Health and
Build a tiered service for preventing the loss of independence that the department would
be responsible for implementing within its own geographical scope
(Ministry of Social
Support and Health).
Adapt the credits paid by the CNSA to the departments according to the achievement of
clear goals, with the goal of greater regional equity
Provide the CNSA
the national implementer of the policy to prevent loss of
with sufficient resources to carry out its work; if necessary, by redeploying
human resources from national social security funds and giving it access to the necessary
data relating to the access of retirees to the prevention service, for all funds
(Ministry of
Social Support and Health and Ministry of the Budget)
Annexe n° 7 : falls: an international perspective
Worrisome “Global burden of disease” data for France...
A problem specific to certain regions of the world
The issue of falls is a problem specific to certain regions of the world. As shown in the
map below, Western Europe is affected by this public health issue with an overall incidence of
12,766 cases per 100,000 inhabitants over 70 years of age (“Global burden of disease” data).
This is the region in which the countries with the highest incidence rates are located. Canada
and Australia are also affected.
Number of falls per 100,000 inhabitants aged 70 and over (declarative data)
Source: Institute for Health Metrics and Evaluation (IHME)
Among the factors explaining these differences is the prevalence of osteoporosis12
(related to sun exposure and skin pigmentation), genetic factors, diet and lifestyle (sitting
cross-legged or sleeping on a futon would have a protective effect).
Osteoporosis is a systemic skeletal disease characterised by decreased bone density and alterations in bone
microarchitecture. These changes make the bone more fragile and increase the risk of fracture. Studies show that
the prevalence of this pathology is correlated to the level of sunshine and the associated vitamin D deficiency.
Europe: a particularly strongly affected region
The Global Burden of Disease results13 are obtained mainly from declarative surveys14
based on questionnaires completed by inhabitants of 22 European countries in 201715, and
especially from the answer to the question, “During the last 6 [sic] at least, have you had a
fall?” .
As shown in the map below, Norway has the highest incidence rate (19,796 falls per
100,000 population over 70 years of age). Conversely, Greece has the lowest incidence rate,
with 7,594 cases per 100,000 inhabitants over 70 years of age. This should be considered in
the context of the prevalence of osteoporosis mentioned above, which is higher in the Nordic
countries where exposure to the sun is less16.
Among the countries most closely studied in the Court’s comparative analysis, France
has the worst European results, after Norway, with an incidence rate of 17,682 (6th position
out of 22), followed by Sweden (10th), the Netherlands (12th), Denmark (13th), the United
Kingdom (16th) and finally Spain, with an incidence rate of 10,161, putting it in 18th place.
Incidence and mortality rate of falls in 2017 per 100,000 inhabitants
over 70 years
Source: Court of Accounts, data from the Global Burden of Disease data tool
Haagsma J. A., Olij B. F., Majdan M., et al.,
Falls in older aged adults in 22 European countries: incidence,
mortality and burden of disease from 1990
. Inj Prev 2020, i67-74, available on
The GBD declarative data may suffer from imprecise collection methods from country to country and therefore
limit comparisons.
Börsch-Supan, A.
Survey of Health, Ageing and Retirement in Europe (SHARE) Wave 5. Release version: 1.0.0
It would be worthwhile analysing these figures in relation to the data on the prevalence of osteoporosis in the
populations of each country. This does not appear to have been done.
With regard to the mortality rate associated with these falls, France ranks behind Norway
and the Netherlands, which both have fall-related mortality rates of around 150 deaths per
100,000 inhabitants over 70 years, compared to 133.5 for France. Further down the ranking
are Sweden (8th), Denmark (9th), the United Kingdom (14th) and Spain (19th). The table is
therefore quite similar to the incidence table
except for the Netherlands, where falls are quite
rare but often lead to death.
This study from the Global Burden of Disease also shows that 2.7% of deaths in France
are caused by falls
the highest proportion in Western Europe after Norway
and that the
reduction in the number of years of disability-free life is 4.1% as a result of falls, a figure that
places France second, behind Switzerland.
Deaths from accidental falls in France among people
aged 65 and over and death rate in 2016
Age classes
Total falls
Rate per
Rate per
Rate per
65-74 years
75-84 years
85 or more
Source: French Public Health Agency (Cépidc): Number of falls and death rate by age and total
death rate by age and sex, France, 2016.
It is interesting to compare Danish and French dynamics: as mentioned above, Denmark
has a fairly good ranking compared to France in terms of incidence of falls, which indicates
that few elderly Danes fall, although osteoporosis is more widespread in Denmark than in
France. In addition, Danes seem to die less frequently from falls. Finally, the number of years
of life lost or lived in disability due to falls is lower in Denmark than in France. This number is
2,162 years per 100,000 inhabitants of Denmark over the age of 70 compared to 2,812 years
in France, which means that the long-term health of Danes is less badly affected by falls than
for the French. The study of changes over time in this indicator also shows a strong decrease
in Denmark between 1999 and 2017 (- 43%).
This is confirmed by objective data on the number of hospitalisations
following falls
To avoid bias related to reporting surveys, the Court collected data from seven countries
on the number of hospitalisations due to femoral neck fractures18 among the 65 and over
group in 2019. France has a higher incidence rate than the Netherlands, Denmark, United
Kingdom19, even though these countries are located further north than France.
Femoral neck (S 72.0), trochanteric (S 72.1) or subtrochanteric (S 72.2).
In the United Kingdom (excluding Scotland), where it was only possible to obtain 2018 data for those aged 60
and over, this rate is 0.45%, compared to 0.49% in France.
Conversely, Spain has a high prevalence (0.7%) with regard to its geographical location
compared to France. Osteoporosis seems to be a very common problem20.
Incidence rate of femoral neck fractures
in 2019
among 65s and over in six countries
Source: Court of Accounts, according to DHFA-DICA registration for the Netherlands, Danish
multidisciplinary hip fracture registry22Toulouse University Hospital and INSEE for France23, Social
Affairs Advisor for Spain, Swedish Ministry of Social Affairs, Norwegian Hip fracture register (only 90% of
fractures are registered).
This graph does not show the incidence rate for Japan which, although increasing,
seems particularly low (0.12% in 2017 for all S 72.0 to S 72.9 hip fractures), which may be
partly explained by a different data collection system.
Unlike European populations, the prevalence of vertebral fractures is much higher in
Japan than that of femoral neck fractures24. However, the difference in incidence between
these two types of fracture, both linked to osteoporosis, is narrowing with rapid industrialisation
and the disappearance of the traditional Japanese way of life (diet, use of futon beds, etc.).
Prevention policies often organised by local municipalities and
precise monitoring of results via registers
, the falls prevention policy takes the form of a guide written by the Public
Health Agency and made available to municipalities. It stresses the importance of identifying
Osteoporosis is a skeletal disorder that affects three million people in Spain. Impaired bone strength puts a person
at a higher risk of fractures, especially of the hip (most severe), spine (most common) and wrists. Although men
have less exposure to this pathology, they suffer more severely from it.
Femoral neck (S 72.0), trochanteric (S 72.1), subtrochanteric (S 72.2).
Period: from 1 December 2018 to 30 November 2019.
A slight underestimation of the incidence rate means that the chain key could not be calculated in the PMSI for
0.5% of stays.
Bulletin of the World Health Organization, Collection of Articles No. 1, 1999.
target groups at high risk of falling. Some municipalities offer group lessons on the importance
of an active life, home or group training programmes and individual medical interviews in order
to identify and reduce risks.
In Norway, a prevention plan for the period 2009-2018 has been drawn up. Its main aims
are to better capture and report data relating to falls, in particular patient type and profile, and
to achieve a 10% reduction in the number of femoral neck fractures over the period.
In Sweden
, municipalities organise “ageing well” prevention and communication
campaigns; e.g. through an annual calendar of tips and advice for the elderly, the promotion
of outdoor sports halls and more participatory and discussion-based workshops around the
expectations of elderly citizens. All ages combined, femoral neck fractures cost the health
system around 1.5 billion SEK (€
150 M) per year, or 2.3 billion (€
230 M) including
rehabilitation. This is the surgical intervention that requires the most resources throughout the
care process.
Measures implemented in the UK in terms of fall prevention are significant (economic
analyses, prevention kits, etc.). In 2007, the National Hip Fracture Database (NHFD) was
established, listing hip fracture data and statistics across the UK.
Similar initiatives for centralised quantified monitoring by other countries in the study
should be noted: the Netherlands, Spain and the three Nordic countries also have online
registers listing the characteristics of patients with hip fractures.
Some figures relating to Spain
According to data collected by the country’s national hip fracture registry, the average age of
hospitalised patients in Spain in 2018 was 87 years; the length of stay was 10 days; 76% were
women; 75% lived at home; 48% were receiving treatment for osteoporosis; and 37% had a cognitive
impairment. These figures are consistent with the results of the study carried out by the Toulouse
University Hospital (see appendix 1).
According to LTC Network’s Cequoa report
, studies on hip fractures in Spain estimate an
average induced cost of €
25,400 per affected patient (including care, rehabilitation and
, compared to an average prevention cost of €
1,197 per elderly person
The Professional College of Physiotherapists of the Community of Madrid (CPFM) estimates
that older people who experience a fall are two to three times more likely to fall again within the year,
and reports that more than 80% of admissions of older people to hospital for injuries are as the result
of a fall (30% of people over 65 and 50% of those over 80 fall at least once a year). According to the
secretary general of the CPFM, 25% of older people who fall suffer injuries that reduce their mobility
and independence. According to this expert, the most common injuries in the elderly are fractures of
the hip, knee or lower leg, superficial injuries such as open wounds, and head trauma.
For this reason, physiotherapists from the four aforementioned independent communities have
issued a series of recommendations aimed at preventing falls
M. Guillen, R. Alemany et al., 2017,
Quality and cost-effectiveness in long-term care and dependency prevention,
Spain Report
Cequoa LTC network.
De la Torre, M., Rodríguez, J. C., Moreno, N., Jacinto, R. L., Hernández, A., Deive, J. C. (2012)
Estudio del
impacto económico de las fracturas de cadera en nuestro medio.
Trauma Fundación Mapfre 23 (1), 15
Riskcenter (2014).
El programa Adaptació funcional de lallar de les persones grans i / o dependents during the
year 2012: avaluació del seu impacte social i econòmic
. Center de Vida Independent, Ajuntament de Barcelona i
Fundació Vila Casas.
Falls are the main cause of injuries in people over 65
60 y mas
magazine, 2015.