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28 February 2022
Communication to the Senate Social Affairs Committee
A need for a new model
Estimated at 2.5 million in 2015, the population of dependent older people could reach 4
million by 2050. Despite the desire of French authorities to promote a “shift towards home”,
établissements d’hébergement pour personnes âgées dépendantes
(EHPADs, “residential
establishments for dependent elderly people”) play a central role in the provision of care,
as they now accommodate around 600,000 residents, i.e., 15% of the over-80 population
living in France. The overall volume of public expenditure allocated to care and dependency
in EHPADs increased by 30% between 2011 and 2019
almost three times faster than GDP
reaching €11.24 billion in 2019. However, this significant increase in expenditure was not
sufficient to meet the needs of an increasingly fragile segment of society. When considering
the challenges of adjusting services accordingly, there seems to be a need for a better
understanding of the development of conditions linked to dependency in the population, in
order to anticipate future needs and to design plans able to meet the challenges. With this
in mind, the Court suggests better integration of EHPADs into the territories, and
strengthening medical care within them, as well as the quality approach.
Chronic shortages of qualified personnel
Although the ratio of staff per resident has increased in recent years, the number of caregivers
remains insufficient to ensure high-quality support. In addition to changing the staff-to-staff
ratio, improving the quality of care involves improving the organisational structure of work and
the distribution of tasks, as well as improving the qualifications and training of personnel, in
particular nursing auxiliaries. It also takes the form of better professional recognition, which
can be a means of attracting and stabilising personnel, whose difficult working conditions result
in high rates of absenteeism and turnover. Moreover, medical services appear to be in
particular difficulty: in half of all EHPADs, there is either no coordinating doctor, or the number
of hours worked is insufficient. And lastly, in terms of prevention, the programmes carried out
are limited in scope, and certain major issues are not given sufficient consideration, such as the
overuse of drugs.
Pricing and contracting methods that are now reaching their limits
The funding of EHPADs is complex. It is based on three sections (care, dependency,
accommodation) and on the almost automatic calculation of allocations based on pricing
equations, aimed at making them more objective. There seems to be a need for simplification
and territorial harmonisation of this funding. Moreover, it is important that pricing equations
take greater account of the specific needs related to the care of residents’ cognitive disorders
and to incorporation of prevention. At the same time, the multiyear agreements on targets and
resources (CPOM), concluded between each manager, the ARS and the department, should be
developed into strategic planning tools given multiyear financial resources. More broadly, a
form of the EHPAD model should be considered, so that it can play the role of a “resource
centre” in gerontology.
Regional care in need of restructuring, structures still too isolated
Although progress has been observed since the health crisis, the structuring of geriatric services
in the territories has remained focused for too long on the area of health, without sufficiently
incorporating EHPADs or home help services. However, their incorporation into a coordinated
territorial organisation would make it possible to adapt the pathways of the elderly according
to changes in their needs. For the Court, this reorganisation must be accompanied by a
strengthening of audits and greater transparency. Four levers have been identified that would
allow the EHPAD model to be changed: greater transparency in the measurement of quality (as
practised in some foreign countries), an overhaul of coordination of care, better adaptation to
the diversity of the groups of public served and more dynamic territorial integration. These
prerequisites should make it possible to move towards a consensual model: that of the EHPAD
“resource centre”, opened on its reference territory, and coordinated with hospital, home and
local authority. This is the model which stakeholders, and in particular, public authorities,
should now be promoting.
Read the report
Emmanuel Kessler
Director of Communications
01 42 98 97 43
Julie Poissier
Head of Press Relations
01 42 98 97 43
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