Currently, there are 7,502 residential long-term care facilities welcoming 610,000 residents. Of these, 50% are public, 31% are not-for-profits and 24% are for-profit. There are 2,294 supported living settings. Hospitals also offer long-term care units, where there were 32,790 patients recorded in end-2015. There are approximately 886,000 people in receipt of domiciliary care, most of which are older people. Nursing and polyvalent domiciliary care services provide services to 125,7000 service users, and domiciliary care services provide care to 760,000 people (source: https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf). In 2015 there were 1.25M beneficiaries of the personal autonomy allowance for people over 60 in need of assistance with activities of daily living. (8% of over-60s) The domiciliary care sector is extremely fragmented, with one department (local authority) having over 100 agencies. Financing is unprofitable. The difference between hourly rates under the personal autonomy allowance  and minimum hourly rates to cover costs were of 2.2€/hour in 2017. Health policies are implemented by the Regional health agencies at the regional level (ARS, created in 2009). Social policies are under the responsibility of the local authorities at the local decentralized level. There is a joint responsibility for tariff setting and financing of operations in care homes. ARS do not have oversight of domiciliary care, except where a nursing component is involved.

France has a population of 67.1 million (2018). In 2018 19.6% of the population were aged 65 years and older (13.1 million people) (source: Statistics France).

In 2015, around 2 million people over the age of 60 were in need of support for activities of daily living, of which 1,459,000 were living at home and 584,000 were living in residential or nursing homes. (source: Sante France) 

The governance of the long-term care system for older people is complex and fragmented, with unclear accountabilities and limited coordination between multiple actors who all have different remits (source). 

Accountabilities lie at multiple levels: national, regional, local-authority. This somewhat fragmented organisation has led to regional variations in access and provision of care services. For instance, Government commissioned reviews have highlighted regional variations in the number of available care services, quality of care, care assessment procedures and cost of care.  

In 2022, a new Ministry for Solidarities and Families (Ministère des Solidarités et des Familles, August 2023) was separated out into a distinct department to the Ministry for Health and Prevention (Ministère de la Santé et de la Prévention). These had previously sat together under one single department, the Ministry for Health and Solidarity. The new ministry also brought together long-term care policy for older people with policy for disabled people (previously under the State Secretariat for Disabled People, Secréteriat d’Etat Chargé des Personnes Handicapées). 

Regional Health Agencies (ARS) were created in 2009 to represent central government at regional level. These agencies have oversight of healthcare and some social care with the ambition of providing some level of integration across the two sectors. However, primary responsibility for social policies, including those relating to ageing, have remained with local authorities (départements). This includes the financing and administration of the cash-for-care scheme (APA; see 1.03), regulation, and long-term planning (see Le Bihan, 2018, download here). The complex accountability arrangements between regional and local resulted in tensions between these two distinct governance levels from the outset of the creation of the ARS, some of which have persisted into the pandemic.  

LTC is characterised in France by a historical separation between care for older people and care for disabled people which is reproduced at all the different levels of governance and organisation of health and social care: While the national fund for solidarity and autonomy (CNSA) was created to cover both working age adults and older age people, there has been limited coordination between the two sectors and there are high levels of fragmentation between the care system for older people and that for disabled people (see Le Bihan 2016, download here). Access and eligibility criteria vary between the two groups, as do benefits (source). The majority of information in this report pertains to long-term care policy for older people unless otherwise stated.  

LTC funding is fragmented and divided across a complex web of actors. Costs are shared between: local authorities, national health insurance (CNAM), not-for-profit (mutuelles) and private insurance policies, National Solidarity Fund for Autonomy (CNSA), central government, pensions, municipalities and individuals.  

In 2014, €30 billion (1.4% of GDP) were spent on policies around long-term care for older people’, of which 80% were state funds. Of this: 

• €12.2 billion were from health spending (of which €12.2 billion were from health and solidarity insurance funds, and €0.1billion were from household co-payments and top-ups) 

• €10.7 billion were from social care spending (of which €3.3 billion were from health and solidarity insurance funds, €4.4 billion from local authorities, €2.1 billion from household co-payments and top-ups, €0.5 billion directly from the state, and €0.3 billion from complementing organisations) 

• €7.1 billion were from housing spending (of which €0.2 billion were from health and solidarity insurance funds, €1.2billion were from local authorities, €3.8 billion were from household co-payments and top-ups, and €1.9 billion were directly from the state). 

The National Solidarity Fund for Autonomy (CNSA) was created following the 2003 heatwave to create protections around dependency and autonomy and is managed by local authorities. It is funded through allocation transfers from the health insurance fund (CNAM) and a tax on capital income and a solidarity contribution for employers and employees. The Act on adapting society to an ageing population (Loi d’adaptation de la société au vieillissement, 2015) introduced an 0.3% contribution through the solidarity fund for autonomy (CNSA) on the pensions of people with an annual income of above 13,956€ (21,408€ for couples) (see Le Bihan 2016, download here). Following the creation of a fifth LTC pillar for as a part of the French social security system in 2020, the CNSA becomes the lead agency for managing this risk.   

This major reform of the financing of the French LTC system had been overdue long before the pandemic, delayed in part as a result of disagreements over financing of the system (see Le Bihan 2016, download here). There has been a long-standing ambition since the 1990s to create a fifth pillar to social security around autonomy and long-term care (see Le Bihan, 2018, download here). The 2019 Libault reform, which set out ambitions plans for reform for which costs would rise to €9.2billion by 2030, promised legislation by end-2019. Options outlined for financing included drawing on existing social debt and introducing mandatory contributions on pay. Due to existing very high levels of taxation on income, drawing on existing social debt and depending on existing taxation was the favoured option. However, the outcome of the yellow jacket (“gilet jaune”) movement and the outbreak of the Covid pandemic led to this reform to be postponed (source). Finally, the Law on social debt and autonomy from August 7th 2020 created the long awaited fifth pillar aimed at financing LTC.   

A market for private insurance for long-term care has developed as contributions are tax-free and is reported to be one of the largest in Europe. Take up is still relatively low, with around 3-5 million insurance policies and unattractive contracts with contributions of €300-500 per month for people with high levels of need (source).  

France’s main policy for older people is a cash-for-care scheme called the Allocation Personalisée à l’Autonomie (APA), which provides some assistance to people over 60 with care needs above a government determined threshold of need (AGGIR 1-6) and is concerned mostly with homecare. In 2020, 53% of the 780,000 people who receive the APA lived at home.1 It is estimated that 2 million people will be eligible to benefit from APA by 2030 (see Le Bihan, 2018, download here). In 2015 there were 1.25M beneficiaries?of the personal autonomy allowance for people over 60 in need of assistance with activities of daily living (8% of over-60s). 

APA is means-tested based on taxable income and some assets (excluding property) (source). Individuals below the lower income threshold of €800 per month do not contribute to the costs of their care. People over the upper income threshold of €2,945 contribute 90% of the costs of their care. The level of the allowance also depends on the need level. ? 

People under 60 or still in employment past 60, in need of support with activities of daily living as a result of disability are entitled to financial support for care services (full compensation if yearly income is under threshold of €27,000 or 80% of cost if over threshold) under the Prestation de Compensation du Handicap (PCH). There were 314,755 people (adults and children) benefitting from the PCH in 2018. 

The average out-of-pocket payment for people drawing on domiciliary care is €60 per month. In residential and nursing care, the average out-of-pocket payment is €1,850 per month (for accommodation), and exceeds the means of more than 75% of people (source). 20% of people in a residential or nursing home are able to benefit from means-tested support for housing (Aide sociale à l’hébergement). The other 55% of people for whom the residential care or nursing costs exceed their income depend on financial support from families or releasing equity from their assets.   

A high number of older people in France live in long-term care facilities (21% of people over 85 live in a care/nursing home; compared to 16% in the UK), although the balance between residential and community care services has shifted as a result of the cash-for-care scheme (source).  

In 2020?there were 7,502 residential long-term care facilities welcoming 610,000 residents. Of these, 50% are public, 31% are not-for-profits and 24% are for-profit. There are 2,294 supported living settings. Hospitals also offer long-term care units, where there were 32,790 patients recorded in end-2015.  

There are variations in quality and offer across ownership types. For example, for-profit care/nursing homes tend to employ fewer staff around resident support and entertainment compared to the public and not-for-profit sectors (source). 

There are approximately 886,000 people in receipt of domiciliary care, most of which are older people. Nursing and polyvalent domiciliary care services provide services to 125,7000 service users, and domiciliary care services provide care to 760,000 people. 

There is no formal definition of quality in long-term care. The 2002 Law on adapting to an ageing society (ASV) outlines components of quality, which include duties for social care providers to internally appraise their quality improvement measures and external inspections from bodies approved by the National Health Authority; an emphasis on respecting user rights; multiannual contracts between commissioners and providers (source). 

The Libault report of 2019 outlines plans to develop quality labels for long-term care facilities, to be managed by the High Health Authority (Haute Autorité de la Santé), and planned for implementation by 2021. The labels would be accompanied by a public dashboard of indicators which would be compulsory for providers to report on.  

The complex and fragmented nature of the care sector, especially in relation to health services, have led to a strong state focus on developing coordinated pathways and intervention (source).  

The complexity of the system has been highlighted as a real concern around access to information and choice of care, prevention, as well as the complexity of administrative procedures involved (source).  

Various schemes have been developed since 2010– the PTA, the MAIA, and PAERPA schemes – having in common the creation of specific functions or professionals to support the social, medico-social and health professionals in their coordination tasks. From a public policy perspective, the analysis of these developments shows that despite their initial objective of improving coordination between the health, social and medico-social interventions and facilities, the creation of three dedicated coordination schemes has also contributed to the complexity of elderly care professional and organizational landscape. Research also highlights limited accountability with poor transparency for users, prospective users and carers (source: CEQUA France Country report (filesusr.com). Since, other arrangements have been developed in including the DAC (schemes to promote coordination) which should merge all other schemes excepting for CLICs which are organised by local authorities. Their implementation is planned to be achieved by July 2022, with the objective to cover the whole territory. Nevertheless, these new schemes – DAC – will need to be aligned with other integrated schemes in other sectors, (e.g. Territorial Health Professional Networks, CPTS in primary care).   

Poor integration with the health care sector has impacted care for people who draw on care. For example, 17% of people over 65 admitted to hospital are readmitted within 30 days (source).  

There are limited information systems at a national level. The regional administrations (ARS) have some level of information collecting. There have been efforts to transfer the recording of deaths away from paper records to a secure app available to doctors (source: https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf).

Around 10% of people over 75 are cared for in residential and nursing homes (source), this represented 728,000 people in 2015 and a 4.8% increase in 3 years (see Le Bihan, 2018, download here).  

Of the 7,502 LTCFs for older people, 50% are public, 31% are not-for-profits, and 24% are for-profit. In the for-profit sector, 10 large care home groups manage 85,000 beds, which represents two thirds of the for-profit sector. On average, there are 90 beds in residential and nursing homes. 15% of beds are in care/nursing homes of less than 60 beds, and 7% of beds are in care homes of more than 200 beds. Care and nursing homes linked to a hospital (EHPAD hospitalier) are larger than the average, with 110 beds (source).  

Day centres and temporary accommodation represent around 4% of provision. The number of autonomy residences (supported living settings) is increasing, with an additional 110,000 new places in 2019. These are mostly public and with lower staff/resident ratios (source).  

The ‘health’ component of services in long-term care facilities are paid for by health insurance, and beneficiaries of the APA receive a small sum towards the cost of their social care each month (see Le Bihan, 2018, download here). However, residents have to pay high costs for the remaining charges including other services and accommodation, averaging €1,850 per month – often exceeding disposable income in more than 75% of cases (source). 

In 2020, the National Assembly noted that the home care infrastructure is largely outdated, often with shared rooms (source:?https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf). 23% of care home buildings had not been built or renovated for more than 25 years according to a 2019 government-commissioned report (source).  

There are variations in the quality of infrastructure across different ownership types. Care/nursing homes with a majority of lower income residents (with a greater share of state support) have limited resources with which to make renovations or improvements. While for-profit care homes offer single en-suite rooms almost exclusively, 11% of public care homes have shared rooms and 25% don’t have private showering facilities (source).   

The Libault report (2019) set out extensive plans to reform care home infrastructure including: renovations and upgrades to existing infrastructure, increasing staff ratios, investing into new models of care such as supported living settings, and developing quality ratings. 

Community based case in France is mostly provided by domiciliary care services: 

• Personal assistance services (Services à la personne, SAP) either directly employed by the person drawing on care or via an agency 

• Domiciliary care services (Services d’aide et d’accompagnement à domicile, SAAD) who give care and support at home 

• Domiciliary nursing services (Services de soins infirmiers à domicile, SSIAD) to deliver medical/nursing care to prevent admission or readmission to acute services and delay a person’s need for residential care  

• Multidisciplinary domiciliary services (Services polyvalents d’aides et de soins à domicile, SPASAD) set up in 2005 to bring together domiciliary care and nursing services to provide a more coordinated approach to care.     

However, a new strategy in 2023 (see 4.08 Reforms to strengthen community based care) has committed to Streamlining existing domiciliary care services to create a single category of domiciliary care provision and move towards a more integrated delivery of care. The reforms will create two main categories of home care: home care with medical/nursing care, and home care with no nursing, but integrated care models will be prioritised through mergers between home care services and home nursing services. New financing from the regional health agencies for the medical component is intended to increase this integration and improve visibility of domiciliary care to health actors. The move towards adopting more integrated domiciliary care services has been informed by an evaluation of existing models which has found more joined up services for people, greater integration with care homes and health actors, and greater prevention (source). 

The domiciliary care sector is extremely fragmented, with one department (local authority) having over 100 agencies. Financing is unprofitable. 

Estimates of the size of provision in domiciliary care are limited due to the varied ways in which it can be purchased: direct service provision commissioned by the local authority (prestataire), partial management of administration by service user (mandataire), direct employment of home care staff by the service user (see Le Bihan and Sopadzhiyan 2018, download here).  The number of people who draw from home care is estimated between 0.4 and 1.5 million. There were over 110,000 places for home nursing care in 2017 (see Le Bihan, 2018, download here).   

The average fee paid to home care agencies who cater to state-supported individuals (around 75% of provision) is €21.7 per hour – below the estimated 24€ needed to cover costs (source).  

People over 60 can access state support for home based care through the cash-for-care scheme (APA). However, the amount people receive is based on low estimates of the cost of care, valued at 60€ per month. This is based only on services included in a person’s care plan, and excludes costs of living, variations on price, and the level of unpaid care from which a person might draw (source).  

There were 3.9 million carers providing care to the over 60 according to a 2019 government report (source). Carers provide on average twice as much care time with users compared to staff (see Le Bihan and Sopadzhiyan 2018, download here). Support for unpaid carers is limited to a right to a break and a right to unpaid leave, although uptake has been low due to limited awareness of the available support (see Le Bihan, 2018, download here). Unpaid carers can receive 500€ as an annual lump sum to fund day care or temporary accommodation. Studies (see Le Bihan, 2018, download here) ) have estimated that almost half (48%) of people who draw on care depend solely on an un paid carer, and another 32% have both formal and informal support. A high proportion of unpaid carers are female, especially in situations of high need. 

There were around 830,000 full-time equivalent people employed in care relating to older people in 2018 (source). The entire social care and social work sector employed 1.9 million people in 2018, which represents 7.6% of the total workforce (source). The distribution of different workforce roles is as follows: 430,000 in long-term care facilities (of which 380,000 in care and nursing homes); 270,000 in home care; 130,000 in domiciliary care nursing.?The average age of care staff is relatively high: 43.6 years. 

Staff report low levels of satisfaction and there are frequent strikes. Only 30% of the workforce is employed full-time and wages are low in the sector (c.882€/month, which is equivalent to minimum wage) (source:?https://halshs.archives-ouvertes.fr/halshs-02058183/document). Wages are comparatively low to other sectors (see Le Bihan and Sopadzhiyan 2018, download here). 

The issues around pay, conditions, and attractivity of the sector have been long-standing. As such, 89% of home care staff are employed on a part-time basis, and an additional 150,000 to 200,000 full-time jobs are estimated to be required by 2030 to meet demand (source). In care homes, staff to resident ratios are in decline (especially in the private sector) and a government-commissioned review had subsequently set the ambition in 2019 to employ an additional 80,000 people by 2024 (see Le Bihan, 2018, download here). France also has some of the highest numbers of accidents reported at work compared to OECD peers, and high levels of staff sickness compared to the national average (source).  

There has been limited success with attempts at professionalisation to improve quality in delivery. Other issues identified include poor managerial practices, intensive working rhythms with limited time and increased needs of people who draw on care, and limited career progression options suited to staff needs.  

Efforts have been made to formalise the sector, with the development of national care diplomas and a professional categorisation and salary increases in some services (see Le Bihan and Sopadzhiyan 2018, download here). 62% of workforce has some level of qualification. Fragmentation and diversity of provision in the sector have created challenges around uniformly addressing pay and conditions: different types of ownership are subject to different regulatory frameworks and protections for employees. Opportunities for training and skills development also vary between staff employed by a care agency compared to those employed directly by service users. 

Due to the limited attractiveness of the sector, there are high levels of vacancies. 77% of home care agencies struggle to recruit, and 63% of long-term care facilities had vacant posts for 6 months or more in 2015, this is especially pronounced in the for-profit sector (source). 10% of long-term care facilities also had vacant posts for coordinating doctors for more than 6 months; 9% of care/nursing homes had vacant care nurse posts for more than 6 months.  

The consequence is pressures on capacity and restrictions on provision. This is especially stark in domiciliary care, 20% of demand for places could not be fully allocated in 2019, 25% of businesses have recorded a decrease in the number of supported places, and over 30% of directors of domiciliary care agencies have highlighted lack of staff as a direct cause of place refusals, moreover, 80% of directors think the situation is worsening. The existence of nursing roles in domiciliary care is an additional pressure, as the gap between pay has doubled (200€) (source:?http://www.senat.fr/rap/r20-199-1/r20-199-11.pdf). 

France is a country with a strong family tradition, where unpaid informal carers have always played an essential role. There were 4.8 million carers recorded in France in 2011. Support for carers is delivered in-kind rather than in-cash. Some of the benefits for carers include the ability to take unpaid leave from employment and paid ‘solidarity’ leave for 3 months with an additional maximum 3 months which must be justified by medical certificate. Although researchers suggested that there is low take up and awareness of these schemes. Other services to support carers include respite care and training (Le Bihan et al. 2017).

References: 

Le Bihan, B., Sopadzhiyan, A. (2017). France Country report. CEQUA LTC Network 

The French care system has been described as complex to navigate, with consequences on user choice and satisfaction as a result with poor access to information and complex procedures to access care.  

A government-commissioned report 2019 found a generally negative view of the care sector in relation to ageing, with those living in care homes reporting a poor quality of life and a gap between the cost of care and the quality of care received (source). The report finds that long-term care in France has too much focus on illness and medical care rather than care that supports people to live independent and fulfilling lives. 40% of French citizens with a relative potentially in need of residential care believe the move to a home will be done against the relative’s wishes; 80% of French citizens consider that entering residential or nursing care means losing choice and independence. 

There are regional variations in the cost of care, amount of financial support received, and quality of care which are not explained by socio-economic of regional differences (source).  

Inequalities also exist around regional coverage.  

Following the 2003 heatwave France had mandated the use of ‘blueprints’ in LTC facilities (and other healthcare settings) to prepare against extreme health events, some of which were triggered in February 2020 (see Le Bihan 2016, download here).  

However, many LTCFs did not have any ‘contingency plans’ which could provide operational support to significant pressures such as high levels of staff absence. Care homes and other LTC actors were not integrated into risk simulation exercises (source:?http://www.senat.fr/rap/r20-199-1/r20-199-11.pdf, see also?Rocard E., Sillitti P. and Llena-Nozal A (2021) COVID-19 in long-term care: impact, policy responses and challenges. OECD Health Working Paper No. 131). 

 

As of Dec 01, 2021, there have been 7,778,575 confirmed cases of Covid-19 in France, and 120,112 deaths attributed to COVID-19 corresponding to 179.11 per 100,000 population. A summary of measures taken is available.

France first published official death estimates for people in care homes on March 31, 2020. Deaths from COVID-19 are recorded where either the death of a confirmed case or a death attributed to COVID-19 by the physician in the medical certificate of death.

Numbers published by the Ministry of Health on April 1, 2021 (Wave 1 & Wave 2), reported a total of 95,264 COVID-19 related deaths, of which 36,889 (39%) were residents in care homes. Of these, 26,044 (71%) died in the care homes and, particularly in the earlier part of the pandemic, were mostly “probable cases” (people who were not tested but a doctor confirmed that the symptoms were associated with COVID-19). The remaining 10,845 died in hospital and were confirmed through testing. As of April 1, 2021, there have been 201,766 confirmed infections among care home residents, and 105,980 among care home staff.

As of January 26th 2022, further data published by the Ministry of Health reported a total of 129,747 COVID-19 related deaths, of which 44,253 (34.1%) were care home residents. Of these, 27,403 died within a care home setting. There are an estimated 605,061 care home beds in France. Therefore, the number of deaths of care home residents linked to COVID-19 would represent 7.31% of all the available beds (Source: https://www.insee.fr/fr/statistiques/3676717?sommaire=3696937).

A 2021 study of the impact of COVID-19 in care homes found that, over the year 2020, 75% of residential and nursing homes had at least one resident infected by COVID-19. 20% of care and nursing homes experienced a critical episode in which at least 10 residents or 10% of the total number of residents died. Over 2020, 38% of care home residents were infected by COVID-19 of which 5% died, amounting to 29,300 deaths. The study finds that care/nursing homes with 24-hour nursing staff were better able to treat serious cases. The study also suggests that for-profit care homes had a slightly greater probability of having a more severe outbreak of COVID-19 compared to homes in the public or not-for-profit sector. Other determining factors include infection rates in the wider community and the size of the care home (source).  

Both senate and National Assembly commissions reported significant issues around access to services in the first wave of Covid-19, both in health and social care, for service users in LTCFs and in receipt of domiciliary care.  

Many home care agencies were forced to prioritise only essential services in the first waves of the pandemic (source). 

Some reports exist of care home residents being refused access to secondary care facilities at the beginning of the pandemic (Sources:?https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf;?http://www.senat.fr/rap/r20-199-1/r20-199-11.pdf).  

The National Assembly report also notes difficult access to medical equipment such as oxygen therapy equipment, and a lack of named GPs within care homes led many care home workers with the responsibility to administer medical and palliative care. 

Both Senate and National Assembly commissions report the impact on wellbeing of the breakdown of care arrangements in the LTC population. There has been significant coverage in the reports, and in media, of the “syndrome de glissement” (slipping away syndrome), due to the depressive effects of isolation on older people, and care homes have been described as transformed from “living spaces” to “medical spaces” (source). The Assembly?report?presents evidence of the impact on physical health due to the breakdown of occupational therapy and physiotherapy support, with considerably higher numbers of older people losing autonomy, and requiring support with walking and other activities of daily living. 

People at home also experienced isolation, especially when living alone, following high levels of staff illness or absence (source).  

A study carried out in the early part of the COVID pandemic investigated the?levels of depression and anxiety of 58 people living in Alzheimer’s Disease in retirement homes. The study sought to identify self-perceived changes in depression and anxiety compared to before the COVID-19 pandemic using questionnaires administered by care staff. It found that participants reported significantly higher depression and anxiety during than before the pandemic. In common to other studies, there were already high levels of depression and anxiety before the pandemic (El Haj et al., 2020). 

References: 

El Haj M, Altintas E, Chapelet G, Kapogiannis D, Gallouj K. High depression and anxiety in people with Alzheimer’s disease living in retirement homes during the covid-19 crisis.?Psychiatry Res. 2020 Sep;291:113294.?doi: 10.1016/j.psychres.2020.113294 

A qualitative study by Giraud et al., (2022) reported that the reduction or suspension of medico-social service worsened the situation of family carers who receive cash for care payments in France. Family carers reported higher levels of fatigue and tensions. Most carers were left on their own with the reorganisation of the care systems and very few received support or guidance from the administration.

References:

Giraud, O., Petiau, A., Touahria-Gaillard, A., Rist, B. and Trenta, A. (2022). Tensions and polarities in the autonomy of family carers in the context of the COVID-19 pandemic in France, 6(1-2): 141–156, International Journal of Care and Caring, DOI: 10.1332/239788221X16316514499801

Over the first two waves of the pandemic, a total of 47,428 cases were recorded among social care staff (source). As of 2 August 2023, 19 professionals are known to have died from Covid-19 across the entire health and care sector. Some 158,336 cases have been recorded among health and care professionals between 2020 and August 2023, with 27,296 care staff cases recorded by survey (source). . 

High levels of staff absences were recorded, and the lack of support to care staff across the sector have contributed to a widespread feeling of anger among staff, who have felt undervalued especially in comparison to counterparts working in health services (source). 

The degradation of working conditions for staff, often faced with difficult choices with little support, and additional tasks, has increased staff exits from the sector and further exacerbated difficulties in recruiting and retaining new staff. (source) 

France recorded high levels of staff sickness, together with poor working conditions for staff entering the profession during the pandemic, and limited support during, led to chronic workforce shortages in LTC sector. Most staff were paid ‘Covid bonus’ of up to €1,500. However, staff shortages, in turn led to care staff taking on difficult tasks (e.g. end of life care) and also contributed to limited access to care.

According to a recent report (February 2022) by The Federation of European Social Employers, France has experienced a strong increase of over 10% in staff shortages since 2021. The sub-sector most critically affected by staff shortages across the countries surveyed for this report were services for older persons. The job position most affected was nursing, but care assistants and homecare / social care workers also face real shortages. The most common reasons given for staff leaving the social care sector for another include low wages, and mental and physical exhaustion relating to the pandemic.

Various reviews and commissions have highlighted many weaknesses with the overall pandemic response. The response in France has notably been described as lacking compared to those in East Asian countries where strict isolation, testing and tracing protocols were in place, which contributed to a rapid spread during the first wave of Covid-19 (source).  

The level of preparedness was described as insufficient due to limited stockpiles of PPE and slow testing capacity; instability within the Ministry for Health and longstanding gaps in the Ministry’s epidemiological and crisis management expertise; and limited information systems. The response in care homes has been especially criticised with limited support and poor coordination with hospitals, general practice, and regional agencies. 

The over-centralisation of governance in France has been outlined as an issue, leading to uncoordinated and overlapping responses between different stakeholders and difficulties acting on the ground. In recognition of the challenges faced during the pandemic, a 50-day consultation titled the Ségur de la Santé was undertaken from 25th May to 10 July 2020 with France’s prime minister, minister for health and care, and representatives from across the sector. The consultation aimed to develop reform plans across the sector, focused on four key dimensions:  

• transforming jobs and developing the attractiveness of health and care careers;  

• developing a new investment and finance policy in health and care;  

• simplifying organisational structures and team working; 

• bringing together regional stakeholders around the common aim of improving care for service users. 

The actions announced in the first wave of the Ségur had a very limited focus on the social care sector, leading the sector to be described as the “forgotten of the Ségur” (les oubliés du Ségur) and reinforcing feelings of being undervalued compared to health (source). As a result, several further waves of action have further brought investment into social care – notably around the extension of salary increases to a majority of care staff (source, see 4.05 for more).  

An expert scientific group was set up on March 12, 2020, and a first lockdown was announced on March 14 (source). 

The French Senate and National Assembly reports on the management of the pandemic were highly critical of the delayed response and support in the social care sector, especially in domiciliary care. Similarly, counting of deaths in care homes was not required until the March 28, and published before the April 2 (Sources:?https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf;?https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf). On March 6, the Health Ministry required the activation of ‘blueprints’, a necessary document needed by care homes and other social/health services to prepare against health crises, in the wake of the high death levels which followed the 2003 heatwave. 

The response in long-term care has been criticised as “modelled on the health sector” (source). 

Coordination between local authorities and regional health agencies has been outlined as a challenge – the limited resources and operational expertise within regional agencies hindered the ability of local authorities to seek out their support (source). Local authorities played a key role in procuring PPE to the care sector – and good practice has been identified where regions supported the procurement of equipment to the care sector.

A national Covid-19 social care task force was set up under the Direction Generale de la Cohesion Sociale [Social Cohesion Unit] (DGCS), announced on March 30, 2020. To prepare for the second wave, the DGCS crisis cell reactivated its ‘open crisis cell’, to function in parallel to that held by the Health Ministry (Source:?https://solidarites-sante.gouv.fr/soins-et-maladies/maladies/maladies-infectieuses/coronavirus/professionnels-du-social-et-medico-social/article/une-cellule-de-crise-de-la-covid-19-par-la-dgcs). All guidance and information pertinent to older people and people with disabilities and?published?by DGCS is available online. 

The crisis cell established in March 2020 included measures to support care homes, including a telephone line with access to geriatricians, a direct route to hospitals, developing hospital at home protocols, and increased support to palliative care. Guidance and directives issued by the crisis cell were coordinated at a regional/local level by the regional health structures (ARS) (source). 

At the onset of the pandemic, significant issues were reported among care homes (and other LTC users) relating to access to healthcare facilities. Many care homes did not have named GPs or equivalent contacts which the Senate/National Assembly attributed to higher deaths. As a result, ‘geriatric territorial support pathways’ and mobile geriatric and palliative care teams for care homes were established on March 31, 2020. The geriatric hotline connected care workers to a geriatric consultant and care coordinator from 8am-7pm 7 days/week. A protocol for pharmacy delivery of indispensable products (e.g. paracetamol) and to connect care homes to pharmacies was also developed in some regions (Source: https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.16687).

A platform was developed in November 2020 for domiciliary/community care providers to pool resources (and regional stakeholders including integrated care pathways, regional health organisations, individual care providers etc.) in a given region to ensure continuity of care and to respond to growing demand (Source: https://solidaritedomicile.fr/solidarit%C3%A9_domicile_informations/solidarit%C3%A9_domicile_information). In May 2020, France was encouraging physician visits and offering greater remuneration after having told homes to minimise such visits in the early months of the pandemic (Source: https://apps.who.int/iris/bitstream/handle/10665/336303/Eurohealth-26-2-77-82-eng.pdf).

The first operational system for documenting the situation in care homes was made available only near the end of March 2020, and publicly available on April 2. Regional structures (ARS) were largely left to their own devices at the beginning of the pandemic. The Health Ministry’s infectious diseases risk register was not adapted to the recording of care home deaths. The Direction Générale de la Cohésion Sociale [General Directorate of Social Cohesion] developed an emergency oversight system on March 28, which was dependent on departments submitting information from LTCFs on observed events (e.g. probable cases, confirmed cases, deaths), recording alerts based on symptoms. This contrasted to SiVIC, the national hospital database, which collected useful personal information. The Senate criticised the system as the ARS regions had to adapt the systems they had developed to a poorer system which wasn’t as useful and required significant resources to extract and convert brute information into something useful (Source: https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf)

The Ségur de la Santé announced significant investments into improving care quality and infrastructure for users and providers of long-term care. This includes: 

• Modernising, renovating, and transforming infrastructure in residential and nursing homes (including also shared living accommodation and other innovative models of healthcare) – €2.1bn over 5 years including €0.6bn for digital  

• Increasing attractiveness of health and care careers through increased salaries, improved conditions, and increased number of places – €8.2bn across health and social care 

• Invest into integrated care pathways for older and disabled people, for example by further developing mobile geriatric teams or strengthened night shift protocols  

• Other investments include €50M to support environmental sustainability in health and care settings, €10M to develop step-up/step-down facilities, €100M around telehealth, €12M in improving access to health and care for disabled people. 

In 2020-21, the long-term care insurance fund was mandated to invest €450M in credit to the long-term care sector, of which €125M of investment for daily improvements.  

High levels of staff sickness were experienced, and as a result, various platforms for redeployment of staff were put in place. Regional platforms put in place by the regional authorities (ARS) were largely more successful than the national platform, which only reached 62 care homes (Sources:?http://www.senat.fr/rap/r20-199-1/r20-199-11.pdf;?https://renfortrh.solidarites-sante.gouv.fr/). 

Almost all local authorities gave domiciliary care workers (Services d’aide et d’accompagnement à domicile) a?Covid bonus?going up to 1,000€ in late 2020. Staff working in residential and nursing homes were also entitled to a?bonus?of up to 1,500€. Health and care workers with a severe form of COVID-19 have been able to claim recognition of occupational disease since September 2020 (source). However, bonuses for care staff were only afforded to care home staff after bonuses were announced for health staff – and only to some domiciliary care staff after negotiations with care federations (source). This has further exacerbated feelings of being undervalued compared to peers in health care.  

Other approaches have been trialled such as the use of used ‘Intermediary Associations’ that are responsible for the reintegration of vulnerable people (out of work), to support social care workers, including in infection control and food preparation etc (Source:?https://solidarites-sante.gouv.fr/actualites/presse/communiques-de-presse/article/crise-covid-19-le-gouvernement-soutient-les-associations-intermediaires-en). 

Qualitative studies into the experience of staff during the pandemic reveal that many were left to their own devices in the absence of clear guidance and direction from national and local stakeholders (source).  

Mobile geriatric and palliative care teams were deployed to care homes from 31st March 2020. The Assembly recommends these be embedded longer-term (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf). 

To support the Omicron wave over Winter 2021-22, guidance was issued on 3 January 2022 which enabled health and care staff to work conditional to them having a complete vaccination cycle (including booster) and no symptoms. It is unclear to what extent this policy has been used.  

Guidance specific to social care was much delayed compared to the health care sector, for example guidance on 20th Feb includes no reference to care homes at all. As a result, 9 large stakeholders wrote to the government and media on 9th March decrying the need for guidance for care homes. Blue plans were activated on 6th March, however a support cell for care homes was only set up on 31st march, which included (source): 

• Permanent access to a geriatrician 

• Mobile geriatric teams 

• Direct admission route to hospitals supported by multi-disciplinary teams 

• Embedding hospital at home measures 

• Support around palliative care. 

No guidance was published for domiciliary care until 2nd April (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf). Guidance since the second wave has been more targeted to specific groups e.g. people with disabilities (https://www.cnsa.fr/documentation/covid-19_-_developpement_des_mesures_dhygiene_au_sein_des_essms.pdf), and require LTCFs to have protocols for infection control (https://solidarites-sante.gouv.fr/IMG/pdf/10_reperes_pour_proteger_les_aines_sans_les_isoler.pdf). 

Guidance has also been developed for infection control among specific groups, such as people with disabilities (https://solidarites-sante.gouv.fr/IMG/pdf/covid_protocole_ph.pdf) and some specific guidance has been published to support older people and protect carers (https://solidarites-sante.gouv.fr/IMG/pdf/plan_protection-personnes_agees_a_domicile-covid-19_1_.pdf?). 

National Assembly report highlights that lack of support to the sector, especially in domiciliary care, meant that many services were reticent to taking on covid-positive service users, leading to discontinuity of care (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf).

Implementation experiences:

Many care homes had to individually isolate service users, especially at the beginning of the pandemic, due to lack of adequate PPE. The guidance published in April 2020 around testing would test the first symptomatic resident, who would then be taken care of either in strict isolation or in single rooms. If one care worker tested positive, all workers were required to be tested and isolate. This was noted as a struggle by the Assembly Commission as many care homes had shared rooms for residents (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf). This was linked to severe health impacts (https://ltccovid.org/2020/05/05/summary-sars-cov-2-related-deaths-in-french-long-term-care-facilities-the-confinement-disease-is-probably-more-deleterious-than-the-covid-19-itself/).

Evidence: 

A study from France comparing mortality in nursing homes with staff confining with residents compared to national average showed that staff confining with residents was effective in preventing infection and reducing mortality (Belmin et al., 2020).

References:

Belmin J, Um-Din N, Donadio C, et al. Coronavirus Disease 2019 Outcomes in French Nursing Homes That Implemented Staff Confinement With Residents. JAMA Netw Open. 2020;3(8):e2017533. doi:10.1001/jamanetworkopen.2020.17533

Visits were suspended in care homes between 11th March and 20th April 2020 with a phased return to ‘normal’ by the summer (16th June). Care home managers criticised the approach of having to set up complex safe visiting protocols from almost one day to the next, and regretted not having been consulted on the proposals (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf). Restrictions on visiting meant that unpaid carers did not have access, with impacts on care delivery and wellbeing (source).  

The announcement of the second lockdown on 28th October 2020 was accompanied by a clear message that visiting in care homes would not be stopped (https://www.francetvinfo.fr/sante/maladie/coronavirus/confinement/confinement-pourquoi-les-visites-en-ehpad-vont-etre-autorisees_4160285.html), with a clear policy to ‘protect our elders without isolating them’ (https://solidarites-sante.gouv.fr/IMG/pdf/10_reperes_pour_proteger_les_aines_sans_les_isoler.pdf). 

Visiting restrictions were relaxed in August 2021 Following the vaccine campaign in 2021-22, protocols prioritised individual rights of social care users which are enshrined in law, including freedoms to see family and to “come and go”. On this basis visits to care homes (and other social care settings) must be guaranteed, transparent information must be given to residents and their families to allow them to make informed decisions.  

Access was made contingent on presentation of the vaccine pass. Visitors were unable to visit residents that have tested positive or that have been identified through contact tracing, except during end of life treatment or if they are ‘slipping away’. Residents spending some time away from the care home are encouraged to be tested upon return. Isolation of these residents upon return is not allowed. 

If three or more cases are identified, the care home must test the entirety of staff and residents.  

Restricting the movement in and out of care homes and other long-term care settings must be the final resort. 

Mandatory vaccination passes were ended in August 2022 but tests may be required in certain settings (source). 

Visits were suspended in care homes between 11th March and 20th April 2020 with a phased return to ‘normal’ by the summer (16th June). Care home managers criticised the approach of having to set up complex safe visiting protocols from almost one day to the next, and regretted not having been consulted on the proposals (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf). The announcement of the second lockdown on 28th October 2020 was accompanied by a clear message that visiting in care homes would not be stopped (https://www.francetvinfo.fr/sante/maladie/coronavirus/confinement/confinement-pourquoi-les-visites-en-ehpad-vont-etre-autorisees_4160285.html), with a clear policy to ‘protect our elders without isolating them’ (https://solidarites-sante.gouv.fr/IMG/pdf/10_reperes_pour_proteger_les_aines_sans_les_isoler.pdf).

From May 19, 2021, visiting restrictions have been further relaxed as a result of increasing vaccine coverage among older people (https://solidarites-sante.gouv.fr/IMG/pdf/allegement_post_vaccinal_des_mesures_de_gestion_ehpad_et_usld.pdf). The most recent protocol refers to the individual rights of social care users which are enshrined in law, including freedoms to see family and to “come and go”. On this basis visits to care homes (and other social care settings) must be guaranteed, transparent information must be given to residents and their families to allow them to make informed decisions. Visitors must be tested upon entry, except where vaccinated. They are unable to visit residents that have tested positive or that have been identified through contact tracing, except during end of life treatment or if they are ‘slipping away’. Residents undertaking outings must wear a surgical mask and be offered a PCR test upon return, and as far as possible they must limit their contact with other residents. Isolation of these residents upon return is not allowed. Restricting the movement in and out of care homes and other long-term care settings must be the final resort.

As with guidance, the sector decried that testing for care homes and in the community was made widely available too late – guidance published on 21st March 2020 limited tests only to symptomatic older people. Changes were made in April to grant priority access to testing for care home workers and residents, to test and isolate the first symptomatic care home worker (leading to isolation of all workers) and the first symptomatic older person, and the following three. On 20th April 2020 pressure was raised to extend tests beyond the first three residents as many asymptomatic cases were missed (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf). It was only from 6th May that all contacts of symptomatic cases were tested (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf). It is unclear how much testing was allowed for domiciliary care workers.

Access to PPE was delayed across the social care sector and is considered by the Senate as the key explanation behind the high level of Covid-19 infection in care homes (http://www.senat.fr/rap/r20-199-1/r20-199-11.pdf). Critics have commented on the over-focalisation in providing PPE to the hospital sector and the insufficient attention given to the care sector by local authorities and health actors (source). Care homes were only included into the PPE provision circuit from 22nd march, despite blue plans being activated on 6th march. Access to tests was heavily restricted (source). 

Until the end of April 2020 there were large insufficiencies in the provision of PPE despite a communication on 13th March stating care homes would have access where need was identified, and central/local conflicts, for example with the state requisitioning regional circuits to social care settings. Domiciliary care settings were hardest hit by PPE crisis, for example with guidance to local pharmacies holding masks to limit use to domiciliary care workers. Some domiciliary care agencies estimate the PPE received covered only 40% of their needs. Even where masks were allocated additional PPE including glasses and FFP2 masks and gowns were not accessible (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf). One inspection authority followed employment regulation and condemned a domiciliary care agency for not having provided adequate PPE to employees (http://www.senat.fr/rap/r20-199-1/r20-199-11.pdf). 

The care sector has expressed a feeling of ‘abandonment’ as a result of the struggles to access PPE, especially in comparison to the health sector which benefitted from a coordinated and rapid response. However, qualitative studies have highlighted the level of community initiatives upon which care providers depended as a result, to help provide home-made PPE etc. 

Investment of 6bn euros across the health and social care system – for renovations and technology upgrades (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf0). 

Telephone support lines were rolled out with some success for support, and according to the DGCS France has performed third worldwide after the US and China in the number of teleconsultations performed over the pandemic, especially in care homes (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf). 

Learning from the first wave helped better shape the response during the second wave, including a greater use of general practice and home oxygen therapy (source).  

In late 2020 priority for vaccination was given to older people residing in collective housing and vulnerable people working there – following recommendations from the High Health authority. Vaccination is free. The 2nd phase addressed those over 75, then 65-74, then health professionals in health and social care over 50, and/or with comorbidities.

To accelerate coverage, a “health pass” was introduced for all people over 17 from July 2021, and for all people over 12 from September 2021. The health pass is required for access to cultural spaces, bars and restaurants, cinemas, and transport, as well as for access to health and social care facilities. The pass is valid if a person has a full vaccination cycle according to the French government (n.b. in France, this includes people with antibodies and a single dose) or a negative test of less than 24 hours. As of 15 December 2021, the “health pass” for those over 65 will not be valid without a booster dose. This will apply for those aged 18-65 from 15 January 2022. In January 2022 Ministers will vote on a law to make the “health pass” into a “vaccine pass”, where negative tests would no longer be accepted as sufficient. The possibility of making the “vaccine pass” a requirement in work and businesses is currently being debated, although unions are strongly opposed to this.

Covid-19 vaccination is mandatory for health and social care staff since 15^th September 2021. This follows a precedent from 2005/6, where legislation was passed mandating a number of other vaccines for health and social care staff. An amendment to the Public Health code of 2016 introduced a condition that health and social care professionals should be vaccinated if it presents a risk to those they care for.

Most recent visiting guidance places the ethical responsibility for vaccination on care staff and highlights that full ‘return to normal’ is not possible without high vaccination rates among staff. Where staff are not vaccinated, they must be ‘very frequently’ tested. 92.9% of staff in care homes have also had at least one dose of vaccine, and approximately 92.2% have had a ‘full’ vaccination cycle. 36.4% have had their booster dose. In September 2021, estimates suggested around 5% of domiciliary care staff had not been vaccinated, but data are limited.

As of 20 December 2021, 92.9% of residents in care homes and long-term care facilities have received a full dose cycle of vaccination, and 64.8% have received their booster dose. The booster campaign in long-term care facilities has been underway since August 2021 and was seen to be more straightforward than the previous campaigns with a high uptake from residents, however fewer staff have been available to facilitate roll-out. Numbers presented by the Minister for Care are higher, claiming that more than 80% of care home residents have received  their booster dose.

A study by the French Directorate of Research and Statistics (DREES) published in November 2021 has looked at the impact of vaccination on infection rates in care homes. They found that a 10 percentage point increase in vaccine coverage among care home residents has led to a reduction of around 20% in the number of confirmed COVID-19 cases. A similar impact has been observed for single-dose vaccinated residents, however the reduction in number of cases is around 10 times smaller. In France, the uptake of the vaccine among residents was much higher in early 2021 than among staff and the authors posit this has made a difference: the number of infection episodes where only staff have been infected has increased from 15% in June 2020 to 60% in June 2021. It is worth noting other factors may have impacted on these results, including restrictions on visiting in early 2021, turnover in residents, and local infection rates.

A?fifth pillar of social security?was introduced around long-term care. Social care policy (termed policy of long-term care) will be steered between the Caisse nationale de solidarite pour l’autonomie (CNSA, which becomes a true insurance fund), and local authorities (the decentralised level). There are?plans?over? 2020-2022 to improve and modernise local authorities’ single points of access for the disabled (Maison Departementale des Personnes Handicapées) or for disabled and elderly (Maison Departementale de l’Autonomie), which help people who draw on care access care and support by providing services such as information, care assessments and planning, follow-up, and medication. The centres are made up of multi-disciplinary teams including doctors, nurses, occupational therapists, care workers, and inclusion specialists. 

Following the?Segur de la sante?(wide stakeholder engagement in 2020 to recover and build resilience in health and care), a national investment strategy was adopted and is devolved from national to regional level. This gives greater decision-making power to regional structures (ARS) to enable them to be closer to local needs and reduce complexity/length of allocation and increase clarity/transparency around decision-making.  

Key measures from the Segur include (sources: here and here): 

• Revaluing the workforce: Pay increases awarded to staff working in health and long-term care 

• Investing in quality of estates: €1.5 billion awarded to modernise care and nursing home infrastructure and develop new models, and €125 million for daily investments (e.g. refurbishments, new equipment etc.) 

• Improving quality of care: Reinforcing hospitalisation at home, mobile geriatric teams, access to end-of-life and geriatric networks through mobile teams, investment in improving care for working age disabled people through e.g. universal access to remote consultation. 

• Investing in data and innovation: €2 billion awarded to health hand long-term care to improve data and digital, including €600 million for care and nursing homes, and with a commitment to creating shared care records accessed by all including people who use care 

Following the Segur de la Sante, France has announced a reform plan in response to the COVID-19 crisis?which proposes numerous measures regarding long-term care which include (among other things): establishing a new financing mix for the supply of LTC (e.g. combining healthcare and social care expenditure in residential care to decrease the remaining amount payable by residents); changing the existing financial support system (e.g. a new cash benefit for homecare); and increasing resources to support informal carers. Additionally, the 2020 law on social debt and autonomy created a fifth sector of the National Social Security System, dedicated to the loss of autonomy of older people and people with disabilities, with EUR 1 billion funding. 

The reform plans are largely catching up on long overdue reform rather than a direct response to pandemic experience (source).  

As part of the reforms following the?Segur de la sante, 2 billion euros have been invested into digital infrastructure, including 600 million euros for care and nursing homes. These investments will enable the creation of an online health and care portal including a shared health and care records, shared messaging system, records and information relative to hospital discharge, etc. (l’Espace numerique de sante). 

The transformation funds from the?Segur de la Sante?will also invest into developing digital tools around ageing and disability, for instance by developing digital integrated care records. 

Following the Segur de la Sante a number of measures were taken to increase the attractiveness of careers in health and care. 

To increase the attractiveness of the residential and nursing home sector as a route of employment, care worker pay was reviewed in 2020 and increased by 183€ per month in public and not-for-profit residential and nursing homes for older people, and by 160€ per month in for-profit care homes (source) 

Criticisms around the disparity in the distribution of salary increases – focused initially only on the public sector for older people – led to an inquiry into increasing attractiveness and salary rates across the entirety of job roles from public to private and for disabled care services also (Mission Laforcade). This has led to a wider approach to salary increases to ensure increases regardless of the financing of employment (whether post is financed through regional health authority or local authority), ownership, and job (e.g. expanded tot include educational support, psychological support etc.) Timeline of salary increases for staff working in long-term care professions, (see here, here, here and here): 

• September 2020. Salary increases for staff working in residential nursing care for older people:  

• Publicly-owned and not-for-profit: 183€ per month 

• For-profit: 163€ per month  

• June 2021. Extension of salary increases to: 

• Staff working in non-nursing residential settings for older people 

• October 2021. Extension of salary increases to: 

• Staff working in autonomous public non-nursing residential settings for disabled people 

• Staff working in public domiciliary care for older or disabled people (13-15% increase based on experience) 

• Staff working in extra care settings 

• November 2021. Extension of salary increases to: 

• Staff working in local authority-funded non-nursing care services (all age) 

• Some staff working private not-for-profit care 

• April 2022. Final extensions to: 

• Staff working in publicly-funded care services previously excluded from other rounds of increases 

• Staff working in specific private not-for-profit care services 

• Other public employment roles, including social workers 

An 2,330 additional training places?for nurses were also created. 

Since the implementation of these measures, some challenges have been observed around their implementation. For instance, not all staff have benefitted from increases to salary depending on how their employer is financed (e.g. by the local authority) (source). Non-care staff (e.g. administrators, technicians…) are also not affected by the salary increases, which is leading staff to exit these roles to other better paid sectors and creating difficulties around recruitment (source).  

In 2019 the country introduced an allowance for people entitled to carer’s leave to encourage carers to make use of the leave, which, at that point, had a low take up (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

In domiciliary care, the Prime Minister announced in September 2021 the introduction of a minimum rate of €22 per hour for home care to stabilise the sector, with the potential to get an additional 3€ per hour for providers who demonstrate a commitment to improvements (e.g. around workforce training, investment in infrastructure, weekend delivery, complex care). The additional total spending for 2022 will be €240million. However, municipalities have estimated that the cost of these reforms is more in the region of €800 million.

Improving infrastructure for older people, and in particular the social care sector, was a key pillar of the French government’s?plan?to “relaunch the economy and make it more resilient” and intends to build a resilient care sector over a journey of 20-25 years. For care homes, 2.1 billion euros have been allocated over 5 years to invest in the transformation, renovation works, and digital upgrading of care and nursing homes. Examples of how this will be used include the renovation of 65,000 care home beds to adapt estates to the futures: buildings allowing for smaller structures with more convivial living opportunities, more rooms adapted to cognitive impairments, and future-proofing estates against climate change. The funds will also build new care homes. 

1.5 billion?euros have been allocated over 4 years to transform models of care homes as part of the Ségur de la santé, into more human, locally connected and medicalised settings. In addition, 125 million euros have been allocated to finance daily needs, such as buying new equipment, small changes and construction works. 

In January 2022, significant media attention was given to the care quality and infrastructure in private residential and nursing homes following the publication a journalist’s inquiry revealing rationing food and hygiene products, with high levels of turnover leading to inappropriate staffing levels. A CICTAR report in February 2022 further highlighted the financially opaque and ‘leaky’ practices within these large private-equity backed care home groups.  The growing media attention suggests the quality and financing of residential and nursing homes, and wider questions around care provision for both older and disabled people, could be a key question in upcoming presidential debates.  

Other measures to improve quality of care and integration of care homes with the health sector include: 

• Doubling financing for mobile geriatrician teams which support residential and nursing homes to €8m per year, which has supported the creation of 177 mobile teams, alongside the development of mobile hygienist teams to build up a culture of Infection Prevention and Control (IPC) more systematically; 

• Strengthening home hospitalisation (akin to virtual wards). The number of residents in care and nursing homes increased by 79% between 2019 and 2020 supported through a relaxing of regulatory conditions to scale and spread models. The long-term financing of home hospitalisation in a wider range of residential care settings is currently being investigated;  

• Establishing geriatric on-call and palliative care for to now cover all care and nursing homes, financed by an end-of-life care plan 2021-2024 and supported with the necessary regulatory changes and support from mobile teams; 

• Development of care and nursing homes and domiciliary care services as territorial resource centres for older people, with responsibilities that include: 

• Providing training for staff, administrative and logistical support, access to geriatric and gerontologic competencies and resources, and facilitating access to specialist infrastructure; 

• Access to more intensive home care support;  

• Strengthening medical support in care and nursing homes, through a budget of €52,2m in 2022 to increase coverage and attractiveness of these roles. Measures include increasing the minimal time of coordinating doctors must spend in care and nursing homes to a minimum of 2 days per week, regardless of the size of the provider, and a monthly bonus for coordinating doctors to €517; 

• Ensuring continuity of overnight care through the scale and spread of night nurses to all care and nursing homes in 2023, with discretion given to regional health authorities around implementation; 

Developing a greater number of specialist settings for care for people with dementia and other neurodegenerative diseases, with additional financing for multidisciplinary teams. (source)