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24 January 2022
Communication to the Senate Social Affairs Committee
A need for changes in provision in closer proximity to the source of
Over the last 40 years, the French population has aged, and we are seeing an acceleration of this ageing
rate as a result of the advancing age of the “baby boomer” generation: according to the INSEE statistics
institute, 20% of the population was 75 years or older in 2019, compared to 13% in 1975. At these ages,
which are characterised by growing rates of loss of independence, the ability to provide home-based
rather than institutional care is dependent on changes in home care provision to offer a better response
to actual needs; for example, by ensuring equity between different geographical regions. The
development of a more inclusive society requires similar changes to the provision for people with
disabilities. This report focuses on four categories of services: home nursing services (SSIADs),
multipurpose home help and care services (SPASADs), special education and home care services
(SESSADs), and medical and social support services for disabled adults (SAMSAHs).
A shift towards home care: little action to date
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, and the expectations of people with disabilities. Despite proactive rhetoric and the
introduction of national plans aimed at improving home care and support services, the share of
residential institutional places continues to represent the majority. As a result, overall provision is
marked by an imbalance between institutions and services, with no clear reduction in regional
inequalities, and no guarantee of support tailored to patients’ individual situations.
Home care services: a valuable resource in a tiered care pathway
The work of home care services is an important aspect of support for those living with reduced
independence. However, nearly 40 years after their creation, the indicators established to measure their
work remain purely quantity-driven, without taking into account the quality or level of care. With regard
to the structure of services, the Court believes that it must be improved and made more transparent.
Changes over time in assessment methods should encourage a quality-driven approach in services.
However, this should not be to the exclusion of increased audits by public authorities.
Regulation of these services must be built into general and regional systems for delivering overall
According to the Court, the ongoing debate between the extension of institutions “beyond
their own
walls” and the development of services is meaningless, because the key issue is to (effectively) remove
the divide between home and residential care. The question of how these new modes of care are
structured forms part of a mechanism for delivering this provision which needs to be implemented as
geographically close as possible to where users are actually located, and must receive support from
monitoring and pricing authorities to create conducive conditions for a care pathway for dependent
rly people with disabilities. The pricing of healthcare services is still currently based on “historical”
block grants, and must change in a way that takes patient dependency levels into account. The long-
postponed funding reform must now be brought to a rapid conclusion, facilitating coordination
measures for those delivering individual care and taking into account the care needs of patients. Lastly,
there is the question of how attractive home care services professions are, particularly for caregivers.
In addition to reassessments of remuneration, the Court calls for a study into working patterns and an
increase in internal promotion, improving career prospects for these professionals.
To remedy all of these shortcomings, this report makes six recommendations.
Read the report
Emmanuel Kessler
Head of Communications
+33 (0)1 42 98 55 62
Julie Poissier
Head of Press Relations
+33 (0)1 42 98 97 43
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