ACCOMMODATION OF

FRENCH NATIONALS WITH

DISABILITIES IN WALLONIA

A new perspective on an original form of cross-border

support

Public thematic report

September 2024

2

Summary report

The departure of French nationals with disabilities to Walloon establishments had never

been examined by the French Court of Accounts. The numerical, financial and social

importance of this phenomenon was highlighted during a previous investigation into the

provision of support for people with disabilities as they age

1

. This observation led the Court to

undertake a specific investigation into the issue.

This report presents the results of this work, which was divided into two parts. The first,

carried out in France in the three regions primarily concerned, provided a portrait of our fellow

citizens currently accommodated in Wallonia. It also examined the conditions for implementing

the moratorium on departures announced by the French government in 2021.

The second part of the study looked at the conditions under which Wallonia’s

accommodation provision has developed over the last twenty years, its specific characteristics

and the inspection arrangements in place for the establishments concerned. This second

phase of the investigation was conducted in close collaboration with the Court of Audit of

Belgium, on the basis of an agreement signed in October 2023 by the two institutions. For the

French Court of Accounts, the work carried out within this framework represented the first

experience of a joint audit with the supreme audit institution of another Member State of the

European Union.

A long-standing and growing phenomenon that the French authorities

have sought to contain

The accommodation of French nationals with disabilities in establishments in Wallonia

2

,

and particularly in the province of Hainaut, is a long-standing phenomenon that grew

throughout the 20th century. Bolstered by geographical and linguistic proximity

3

, the continuing

development of the Walloon accommodation offer is explained by a legal framework that has

long been less restrictive than that applicable to French operators, by a policy, widespread

throughout Europe, of reducing the number of beds in psychiatric institutions, and by the quality

of the support offered

4

.

The ease with which establishments could be set up, combined with the certainty that

places would be available and that they would be financed by French public funds, either from

the health insurance system or from the departments, attracted entrepreneurs from a variety

of backgrounds, sometimes far removed from the medico-social field, to work alongside the

long-established operators who had been present for decades.

Provision has grown steadily

5

to the point where there are currently just under

8,200 French residents (around 7,000 adults and 1,200 children, adolescents and young

1

French Court of Accounts,

L’accompagnement des personnes en situation de handicap vieillissantes

, thematic

public report, September 2023.

2

Wallonia is made up of five provinces: Walloon Brabant, Hainaut, Liège, Luxembourg and Namur.

3

The Walloon region shares a 300km border with France.

4

In terms of autism care in particular, the practices of Belgian professionals were considered to be more innovative

than those implemented in France.

5

11 establishments were authorised to provide care in 1997 and 143 in 2016 (joint committee of November 2016).

3

adults), according to data reported by the establishments

6

. Its cost to the French public purse

is estimated by the French Court of Accounts at

€

0.5 billion per year

7

.

To contain the twofold increase in departures and expenditure, the public authorities

have implemented two policies, successively or concurrently depending on the year : one

aimed at preventing departures by developing solutions throughout the country and organising

the identification and support of the complex situations most likely to give rise to a request for

referral to a Belgian establishment ; the other, more recent policy, sought to contain the

development of supply by limiting the number of places authorised and controlling the related

expenditure within a closed budget.

The moratorium on the accommodation of adults in Belgian establishments in 2021 is

the result of this dual approach. It restricts supply, which is frozen as of 28 February 2021, and

organises a local response in France by delegating

€

90 million to the Grand Est,

Hauts- de- France and Île-de-France regional health agencies.

The number of people accommodated in Belgium highlights the

shortcomings of the French system

The first aim of the investigation was to describe the adult population accommodated in

other parts of the country, in order to determine what needs were being met by the Belgian

system that were not being met in France. By analysing census data

8

and a sample of records

for people accommodated in Wallonia, it was possible to draw up a typology.

While those accommodated in Belgium are not radically different from those remaining

in France, there is an over-representation of people with the least access to French medico-

social establishments and services

9

. A large number of people suffering from behavioural and

conduct disorders, combined with a mental disability or intellectual impairment, are thus

present in Belgium. The accommodation of these people is a specific feature of the Belgian

system.

It has also been possible to document the disruptions in people’s lives that have led

French nationals to move to Wallonia: transition to adulthood without a place in French medico-

social establishments and services, presence in Belgium since childhood, exclusion from the

French medico-social sector due to serious behavioural problems, people leaving long-term

hospitalisation in the French psychiatric sector, arrivals following the breakdown (death,

illness) of the family caregiver.

Support solutions designed to prevent people from leaving are only

partially able to meet their needs

The investigation also aimed to measure the effectiveness and relevance of the

alternative solutions deployed in the three eligible regions with the help of the

€

90 million

funding.

An examination of the conditions under which these funds were used and the solutions

they financed leads to a critical assessment of the adequacy of the solutions proposed to

compensate for the cessation of departures. The persistence of requests for first referrals to

6

For an identical scope (i.e. children and adults in medical and non-medical care), no data is available to measure

this growth over more than ten years. However, it is known that 1,472 people were covered by the health insurance

scheme in 2013 and 4,115 nine years later.

7

Medical and non-medical accommodation of adults and children.

8

Reported by Belgian establishments, these lists of residents are known as “

relevés d’informations

” or, more often,

“

cadastres

”.

9

French Court of Accounts,

L’accompagnement des personnes en situation de handicap vieillissantes

, op. cit.

4

Belgium testifies to the inadequacy of the solutions funded, both in number and in terms of

their suitability for the needs expressed.

With the

€

90 million resulting from the moratorium

10

, the Grand Est, Hauts-de-France

and Île-de-France regional health agencies have financed more than 1,800 alternative

solutions to departure. Full-time residential places accounted for less than a third of these

solutions (28 %). Most of the funding was for home services and, in the case of institutions, for

temporary accommodation, day support, specialised guest house or assisted living centers,

either off-site, at home or outsourced.

These solutions, which are in line with public policy on inclusion and the development of

alternatives to institutionalisation, are not, however, adapted to the situations of those seeking

a place in Belgium. The departments of the three regions consulted by the French Court of

Accounts confirm that complex cases, which are the most likely to move to Wallonia, require

care in permanent accommodation, which is insufficiently represented in the solutions funded.

Furthermore, these 1,800 solutions have not succeeded in reducing the territorial

imbalances in the Île-de-France region, which call for a significant increase in the resources of

the departments with the least resources and customised solutions to encourage innovative

projects.

In addition to the transformation of France’s medico-social services, the investigation

also looked at the conditions under which Walloon establishments accommodating French

nationals are developing and the control mechanisms in place.

Mechanisms for monitoring the proper use of French public funds require

strengthening

Ten years after the entry into force of a framework agreement between the French and

Walloon governments, signed on 21 December 2011 and providing in particular for the

implementation of an ‘efficient joint Franco-Walloon inspection system’, a review of the

procedures and inspections of establishments carried out jointly by the Walloon Agency for

Quality of Life

11

and the Regional Health Agency Hauts-de-France has been conducted.

150 reports drawn up following these inspections were analysed.

The findings show that, since 2015, serious failings

12

have been identified in more than

60 establishments

13

. According to the competent authorities, this type of failure affects around

twenty facilities accommodating people with disabilities in France every year. In the French

Court of Accounts’s view, the repetition and seriousness of the observations made by the Aviq

and the Regional Health Agency Hauts- de-France call for a thorough review of the ways in

which the authorities in charge of this issue on both sides of the border work together.

France spends around

€

0.5 billion a year on accommodating French nationals with

disabilities in Wallonia. Control of the proper use of these funds by the funding bodies is also

inadequate.

10

Taking into account the amounts allocated since 2016, the regional health agencies have obtained a total of

more than

€

169 million to fund measures to prevent departures.

11

Walloon agency responsible for issuing approvals to establishments accommodating residents with disabilities,

as well as related controls and inspections, whether or not carried out jointly with the Regional Health Agency Hauts-

de-France.

12

Physical or verbal abuse, deprivation of food as punishment, lack of care leading to death, spoiled foodstuffs,

rationing of meals, poorly maintained or dilapidated buildings, lack of supervision putting residents at risk,

negligence in the distribution of medication, lack of respect for privacy and intimacy, improper invoicing using

residents’ Vitale cards, financial fraud, etc.

13

The Court’s calculation is based on joint inspection reports drawn up since 2015, pre-agreement visits carried

out by Regional Health Agency Hauts-de-France in 2021 and 2022 and reports made to the Public Prosecutor since

2020.

5

Many French residents and their families would not consider living anywhere other than

Wallonia. Some young people who have been accommodated since childhood wish to

continue their adult lives here. The moratorium of 2021 did not mean the end of this

cross- border cooperation.

Consequently, the French Court of Accounts calls on the French authorities to be more

vigilant regarding the quality and safety of the care provided to these residents, which must be

comparable to that expected of the establishments under their direct supervision. At present,

this condition is not guaranteed everywhere.