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A need for improved service provision in the
form of a regionally-based strategy of tiered
Communication to the Senate Social Affairs Committee
December 2021
Executive summary
This report examines four categories of services: home nursing services (SSIADs);
multi-purpose home help and care services (SPASADs); special education and home care
services (SESSADs); and medico-social support for disabled adults (SAMSAHs). These
medico-social structures specialise in care and home support for dependent elderly people
and people with disabilities.
A shift towards home-based care: often promised, but with little
action to date
International studies
mainly those carried out by the Organization for Economic Co-
operation and Development (OECD)
paint a picture of a France in which support for
dependent elderly people is provided mainly within shared residential structures.
An imperfect interpretation of Franc
e’s slowness in moving to home care
However, this observation must be treated with caution: international comparisons are
based on somewhat nebulous concepts and do not take the various different contexts
institutional, demographic, geographical, etc.
into account. A number of incomplete
computations weaken the scope of the conclusions still further. Even so, a few foreign
experiences can provide inspiration for the future shape of French policy, but they are not
directly transposable. In any case, such studies cannot be used as evidence that France is
falling behind in terms of home care. At best, it can be observed that the number of places in
medical institutions, relative to the population of people aged 65 and over, remains stable in
France, whereas it is decreasing in the Nordic countries.
A predominantly institutional emphasis on services
In France since 2005, public authorities have favoured a “shift towards the home”, in
response to the wishes of a growing proportion of the population at risk in the short of medium
term of facing reduced independence, or already facing such issues in caring for elderly
relatives, and at the request of people with disabilities. In practical terms, however, the care
sector continues to be characterised by its reliance on institution-based services, despite the
fact that the proportion of home care services has increased, particularly among dependent
elderly people and young disabled people. This development is the result of major national
plans which significantly increased supply, but whose expiry has led to a marked slowdown
in the creation of new places over the past four years. The provision of new places failed
either to make the promised “shift towards the home” a reality, or to harmonise resource
levels in institutions and medico-social services.
Abundant data collection, but with little strategic implementation
To date, no needs analysis exists to enable plans for an improved service offering to
be drawn up. However, studies and data relating to the medico-social sector have proliferated
in recent decades. Designed with a price-driven philosophy in mind, and driven essentially
by statistics, they are mainly limited to describing the existing situation and do not provide
any qualitative assessment of needs, or even examine the relative effectiveness of the
various support methods (particularly in terms of avoidable hospital emergency visits). Work
on the Resid-ESMS database, which links expenditure for service users across the three
health sectors (community medicine, medico-social structures and health institutions), has
fallen behind schedule, with the CNAM having omitted it from its work programme until the
second half of 2021, despite an initial prediction of results by the end of 2019. Unlike its
predecessor, Resid-Ehpad, this tool
which is essential for overall medical expenditure
is intended to be widely distributed not only to national decision-makers but also
to local pricing authorities and managers, in order to measure the effectiveness of medico-
social support and to be able to direct care more efficiently.
A demographic shock requiring an effective effort to create extra places
in the home
Before there can be any acceleration of the “shift towards the home”, the demographic
shock generated by the ageing process will require the creation of a large number of places
for home services simply to maintain resource levels and the share of home-based care at
their current levels.
The finding that public expenditure on home-based care works out at half the cost of
institutional care needs to be put into perspective: it can only be confirmed by a comparison
of home support services in their entirety
delivered mainly by home help and assistance
services (SAADs) which provide household services and assistance with daily living
medical institutions, which are staffed with doctors and qualified nursing staff. On the other
hand, the public costs are comparable if such comparisons are restricted to technical care,
as demonstrated by the Court by comparing the average public expenditure per place
between SSIADs and residential care homes for dependent elderly people (EHPADs).
Regulation should be extended to community care
Even more than in institutions, home care services falling within the medico-social
sphere are located at the intersection of the community medicine and hospital sectors. Any
evaluation of the expenditure associated with such care must therefore go beyond mere
consideration of the general objective of medico-social expenses (OGDs), and the pursuit of
efficiency should apply to all budgets. However, although France’s medical/social national
healthcare expenditure target (ONDAM) and its hospital ONDAM have been subject to tight
regulation, the ONDAM covering community care is a “leak”
in the system that it seems
necessary to stem. In particular, expenditure on nursing care services (AISs), which equates
to hygiene care
in respect of which the Court of Accounts had already noted the inequality
of regional distribution and pointed out the correlation with numbers of independent nurses
needs to be subject to stricter supervision.
Home care services : a valuable resource in a tiered care pathway
Support via SSIADs or SPASADs as an effective alternative to nursing homes,
for dependent people, providing them with a supportive social environment
SSIADs are essentially providers of basic face-to-face care provided by nursing
auxiliaries, enabling an efficient delimitation of tasks between the professionals providing
To date, salaried nurses have generally been assigned to supervising nursing
auxiliaries, coordinating with other providers of care, assessing the situations of individuals
and drawing up care plans. Technical nursing tasks are carried out mainly by contracted self-
employed nurses. However, in the absence of caregivers, SSIAD-based care is less ideal in
more severe cases. Experiments with “strengthened” SSIADs offer a means of providing care
for more dependent people but, given their high cost, such places should be reserved for
acute short-term situations.
To provide care that is more tailored to people’s real needs and avoid the provision of
multiple services of a comparable nature (figures show that three-quarters of SSIAD patients
have concurrent professional help at home), services providing multipurpose help and care
at home (SPASADs) need to be developed, provided that funding is available for the
coordination time required for their implementation, and assuming they are staffed with
personnel able to implement preventive measures (psychologists, occupational therapists,
psychomotor therapists, etc.).
Efforts needed to set up support programmes for people with disabilities
The SAMSAHs are divided into provider services and care coordination services. In
both cases, the educational and social support dimensions are the most significant in terms
of volume, but the care services they deliver are decisive for their patients, and must remain
In light of national data, however, the SAMSAHs seem to act less as an entry point into
the medico-social sector than as a support tool for caring for people at risk of health and/or
social breakdown and enabling them to remain in their usual living environments. However,
the disparate range of programmes provided for by law does not make it easy to understand
their respective remits.
The SESSADs provide families with “all
inclusive” care support, excluding travel or
other expenses. They are focused on supporting age groups subject to compulsory
education. However, they do not completely remove the risk of school drop-out
an issue
which needs to be treated as a priority. The lack of support for the youngest age groups
needs to be mitigated by raising the age of compulsory education, and corrected by reform
in authorisations, lowering age intervention thresholds. But there will still be a need to relax
the terms under which SESSADs operate, particularly by making it possible to deliver
services prior to notification of the CDAPH (commission for the rights and independence of
handicapped people). For older age groups, support must be better linked to their integration
into a professional career; further provision in this area, involving ordinary and adapted
environments, is also needed.
A need for more transparent operating methods
Home care services are faced with the unanswered question of how to measure their
activity. While services involving technical care are covered by the NGAPs (general
nomenclatures of professional acts) that apply to private practice, the same is not true of
basic care services. The social component of such work is difficult to quantify. To do this, it
is essential to go beyond the work carried out under the aegis of France’s CNSA agency,
which has resulted in the production of a list of services, but provides an insufficient
framework for the production of data. A regular system is required for measuring activity on
the basis of the active patient population and collecting more quality-driven information. To
this end, the “digital ESMS” programme must be comple
ted and work organisation solutions
developed to help optimise staff interventions.
The issue of service structure continues to require energetic action: time slots must be
tailored to address the needs of vulnerable groups. This is particularly true of the SESSADs,
which must be able to operate outside of school hours. There must also be an emphasis on
bringing together managers (who are still too fragmented), making control over their
administrative and financial management more effective. The goal would be to reach a
sufficient critical mass to make it easier to offer full-time jobs to caregivers and provide a
greater scope of activity for other health professions. There is also a need to guarantee the
quality of the services, which could be facilitated by reforming procedures for assessing the
services. Lastly, local authorities require a greater monitoring capability.
Regulation of these services must be built into general and regional
systems for scheduling all care
The improvement of home care provision is based on a threefold consideration: a more
regionally-focused care structure; resource allocations that are geared towards care services
efficiency; and improved human resources management.
Efficiency of home care services to be improved through the creation of a
tiered regional care structure
Service improvements will be all the more effective if they form part of a strategy of
tiered care delivered within integrated health ecosystems. Regional Health Agencies
with their ability to sign agreements on targets and resources with certain private
health practitioners, hospital managers and managers of ESMS
are in possession of the
tools likely to facilitate improved coordination of interventions with patients and streamlined
care pathways. Their role is to effectively provide such coordination within local communities
and, to do this, they need to be equipped with the necessary knowledge and resources.
A need for changes to the funding of home care services
Funding by “historical” block grant e
ntails very disparate pricing, which cannot be
explained by differences in the level or nature of the support provided.
Reforms of funding rules have consistently failed for more than 10 years; in the case of
the SSIADs, this has been particularly due to the absence of financial support for the change.
The phenomenon of joint funding by health insurance and the county council, used in the
case of the SPASADs and the SAMSAHs, seems to be less of an issue than the lack of
funding to date for the coordination time required between stakeholders.
There is consensus on the need to end historical service grants. Their pricing structure
needs to take more consideration of patients’ levels of dependency. With regard to services
for people with disabilities, while it may be somewhat problematic to price them on the basis
of an assessment of patient dependency, given the lack of currently available tools, it is
important to avoid the disincentive effects of block grants and identify additional specific
funding for missi
ons of general interest or support for “complex cases”, via multiyear
agreements on targets and resources (CPOMs).
A need to increase the attractiveness of professions in the medico-social
The attractiveness of home care services is a particularly relevant issue for caregivers.
Despite the fact that current negotiations on the revaluing of their remuneration packages
should be completed and come into force later in 2022, it is advisable to study factors such
as working patterns and an increase in internal promotion, improving career prospects for
these professionals.
Amend regulations in order to broaden access to Resid-ESMS data to include central
government departments responsible for scheduling, Drees (Department of Research,
Studies, Evaluation and Statistics) and the ATIH (Technical Agency for Information on
Hospital Admissions), to enable them to be cross-linked with databases on independent
living, and to permit access to the results of the use of these data for each structure, to
the RHAs and managers, as part of the establishment of CPOM agreements (
Ministry of
Solidarity and Health).
Verify the effective implementation of a repository of user complaints, declarations of
serious adverse events and internal and external audits on compassionate care
Regional health agencies
Add to the existing indicators in order to better measure the activities of care services
and standardise the reports sent to the RHAs (
Ministry of Solidarity and Health and
National Solidarity Fund for Independent Living
In agreements between the ministry and the RHAs, introduce a quantified objective for
the development of regional coordination between medical-social institutions and
services, health institutions and health professionals acting within coordinated
operational structures, and also related resources (
Ministry of Solidarity and Health
Set up funding for home care services that is tailored to the level of care provided, with
a regular review of the measurement of dependency among the elderly in line with a
process of tacit agreement, which includes a component linked to their performance and
takes account of the coordination times necessary for their work to be effective (
of Solidarity and Health and National Solidarity Fund for Autonomy
Enhance the career prospects of nursing auxiliaries, in particular access to the nursing
profession, and advocate for changes to their terms of employment so as to reduce the
enforcement of part-time working arrangements (
Ministry of Solidarity and Health
Annex 3: establishment and limitations of international
Some definitions and comparisons
The comparisons relate to expenditure on LTC, the concept that comes
closest to medico-social support for dependent people
(elderly or disabled).
In 2019, according to Drees
, long-term care expenditure in France stood at 1.8 points
of GDP (care component), a level comparable to other European Union countries. The most
advanced countries in terms of long-term care, according to these comparisons, are
essentially Nordic countries (Sweden, Norway, Denmark).
Long-term care expenditure relative to GDP
health component
Sources: Health account 2020
International comparisons from: OECD, Eurostat, WHO,
International System of Health Accounts (SHA).
However, this comparison does not take account of a portion of the expenditure on
services or social assistance providing support for dependency and disability
a so-called
“social” component for which the supply of data in the int
ernational System of Health
Accounts is sparser. In respect of this social component, France is in the mid-range of
countries that have provided information (with 0.6 pts of GDP which, when added to the health
component, brings it to 2.4 pts of GDP for LTC expenditure); only Denmark and the
Netherlands show significantly higher expenditure on this component.
Health expenditure in 2020
Health accounts results
2021 edition.
On the other hand, according to the OECD, France appeared in 2017 to be losing
ground, because among the beneficiaries of LTC
, 59 % receive care at home, compared to
an average figure of 68 % for OECD countries. In line with their position on LTC expenditure,
the Nordic countries are among those with the highest coverage rates (around 75 %).
Long-term care recipients aged 65+ receiving home care
(year 2017 or nearest)
Source: OECD Health Statistics 2019
International definition of LTC expenditure room for improvement
Under this definition, long-term care includes health and social services provided to
dependent individuals in need of continuous care.
In addition to just health expenditure, the health component includes assistance such
as the disability compensation benefit, the disability compensation allowance and assistance
with basic activities of daily living (ADLs
The social co
mponent essentially covers aid for “instrumental activities of daily living”
With regard to this definition, the margins of interpretation are wide because the division
between (a) curative and “rehabilitative” care and (b) long
-term care can prove to be complex.
Similarly, the distinction between ADLs and IADLs
is difficult to quantify (for example, it
In this case, LTC recipients are APA (personal care allowance) recipients.
This constitutes the difference between (a) current health expenditure in the French sense, or DCS (which does
not take these services and assistance into account), and (b) current health expenditure in the international sense
(DSCi), which takes them into account.
“Assistance relating to the performance of basic activities of daily living” (ADLs) refers to the assistance given to
people so that they can get up, wash and dress, feed or use the toilet. “Assistance relating to the performance of
al activities of daily living” (IADLs) refers to assistance with performing domestic tasks (shopping,
laundry, cleaning, etc.), or administrative tasks (budget management).
requires separating what items fall under each of the two categories of assistance within the
APA personal care allowance).
The difficulty of identifying what falls under the social component of long term care
(generally home care), and what falls under the health component, which is not subject to
harmonisation, reinforces the complexity involved in international comparisons.
OECD institutionalisation rates (number of beds in medical institutions per 100
inhabitants aged 65 and over) show nuanced movements from one country to another.
In fact, to a greater extent than the comparison of levels in 2019, it is the dynamics at
work in the various countries that are the most instructive in terms of their differences.
Number of beds in medical institutions per 100 inhabitants aged 65 and over
(from 2005 to 2019)
Source: OECD data.
Countries such as France or Germany did not generally experience a clear change in
resource levels for institutional places between 2005 and 2019. At most, there was perhaps
evidence of a slight upward trend for Germany over time, while France seems to have been
engaged in a very slightly downward shift since 2011.
The situation is different in Nordic countries such as Norway, Denmark and Sweden.
Their long-term trend away from institutionalisation is clear, but its origins lie in resourcing
levels for institutional places that were much higher than in the case of France or Germany.
This continuous decline in resourcing levels for institutional places with regard to the elderly
population meant that in 2019, Denmark and Norway displayed lower resourcing levels than
their partners. On the other hand, this is not the case for Sweden, which has certainly greatly
deinstitutionalised the services it offers, but still today maintains resourcing levels for
institutional places that are much higher than those in France or Germany.
Nombre de lits en institutions médicalisées pour 100 habitants de 65 ans et plus
The Spanish example offers a better understanding of the difficulties of
In Spain, institutionalisation levels for the elderly vary by as much as 100% depending
on the source of the data: from 1.8 % (according to the OECD) to 3.5 %, according to the
public institute responsible for independent living (Imserso), and the Spanish National
Statistical Institute (INE) in 2016 (latest data used in Imserso’s report on the elderly
This difference can be easily explained in the case of Spain. The first measurement
lists only institutions tha
t are deemed to be “public”, while the second lists all institutions.
However, in Spain, to obtain payment of the individual SAAD (“Sistema para la autonomía y
atención a la dependencia”) benefit, and thus qualify as “public”, institutions must satisfy a
ertain number of conditions and meet quality standards. This distinction between “public”
and “private” institutions also reflects differences in the quality of care for the elderly.
What are the key facts for France in terms of the institutionalisation rate?
If we consider the OECD data, which better reflect the social model of care for the loss
of independence, France has an average level of institutional care compared to our main
neighbours in the EU. Using a slightly broader approach to institutional levels (the approach
used by the statistical institute), France still seems to be at a level close to that of our main
neighbours, Germany, Belgium and the Netherlands, but higher than that of the countries of
northern Europe.
France has not experienced a shift away from institutionalisation. While the northern
countries (Sweden and Denmark exclusively) and the Netherlands may have initiated this
shift, they also previously had levels of institutionalisation much higher than those of France
(often double). Finally, among the countries offering the lowest levels of long-term care, such
as Spain, we are witnessing a shift towards institutionalisation, with the creation of a large
number of institutional places.
In conclusion
The fragility of international comparisons makes it impossible to issue a definite verdict
on France’s place in terms of long
-term care at home relative to its other OECD partners.
On the other hand, France is not experiencing any deinstitutionalisation movement,
whereas the Nordic countries (which are the most advanced in terms of home care) are
experiencing consistent reductions in the number of institutional places relative to their
population aged 65 and over.
Imserso (2017),
Informe 2016. Las personas mayores en España. Datos estadísticos estatales y por
comunidades autónomas,
Colección Personas Mayores
Serie Documentos Técnicos y Estadísticos.