COVID-19 and the Long-Term Care system in France

Structural characteristics of the LTC system, impact of the pandemic, measures adopted and new reforms

This country profile contains a section of the LTCcovid International Living Report on COVID-19 Long-Term Care that brings together information on the experience of the long-term care sector (focussing on people who use and provide care) during the COVID-19 pandemic in France, as well as description of the system and of new reforms. The LTCcovid Living report is updated and expanded over time, as experts on long-term care add new contributions. This profile also provides links to research projects on COVID-19 and long-term care, to key reports, and lists key experts on the impacts of COVID-19 on the long-term care sector in France.

Experts on COVID-19 and long-term care in France that have contributed to this report:

Camille Oung

Living report: COVID-19 and the Long-Term Care system in France

PART 1 – Long-Term Care System characteristics and preparedness
  • 1.01. Population size and ageing context
    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).
  • 1.02. Brief description of the Long-Term Care system

    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.

    Authors: Alis Sopadzhiyan (LTCCovid profile pending)

  • 1.03. Long-term care financing arrangements and coverage

    In 2016 public LTC expenditure in France was estimated to represent 1.7% of Gross Domestic Product (https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf).

    LTC funding is fragmented and divided across a complex web of actors, at a local level (local authorities), health insurance (CNAM), not-for-profit (mutuelles) and private insurance policies, National Solidarity Fund for Autonomy (CNSA), central government, pensions, municipalities and individuals (source: https://www.alzheimer-europe.org/Policy/Country-comparisons/2007-Social-support-systems/France)

    In terms of public spending, costs are shared between: National Solidarity Fund for Autonomy (CNSA), regions, the state, which in 2011 contributed approximately 9.7bn€, health insurance (CNAM), which contributed 11bn€, accommodation costs 7.5bn€ adding to a total of 21bn€, which amounted to 1.05% of GDP. Including the costs of household contributions would brought total spending to 28bn€, 1.41% of GDP.

    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 – although take up is still relatively low.

    The country’s LTC policy is based on cash-for-care scheme called the Allocation Personalisee a 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 2018 8% of people over 60s were APA beneficiaries. APA is means-tested based on taxable income and some assets. There are high levels of out-of-pocket payments, individuals pay up to 90% of the care costs. For example, whereas individuals with below a monthly income of €800 do not contribute to the funding of the care, those with income of above €2945 contribute 90% of the care costs. Moreover, the level of the allowance depends on the need level.  Median cost of a room in a care home in 2018 was 1977€.

    There were 4.8 million carers recorded in France in 2011. France is a country with a strong family tradition, where unpaid informal carers have always played an essential role. Support 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 (sources: CEQUA France Country report (filesusr.com)https://halshs.archives-ouvertes.fr/halshs-02058183/document).

    Author 2: Alis Sopadzhiyan (LTCCovid profile pending)

  • 1.04. Long-term care system governance

    France has a highly fragmented LTC system with operations at multiple levels at national, regional and municipal levels and significant regional variation. There is also limited coordination across actors, which all have different remits. Local authorities (departements) have the primary responsibility for social policies including those relating to age.

    Regional Health Agencies (ARS) were created in 2009 trying to represent central government at regional level, which resulted in expansion of remit of regions to social care as well as health. Regional structures (ARS) have oversight of healthcare, and some social care which is designed to provide some level of integration across the two sectors.

    Author 2: Alis Sopadzhiyan (LTC Covid profile pending)

  • 1.05. Quality and regulation in Long-term care

    No formal, comprehensive definition of LTC quality has been produced by national or local public authorities. Nevertheless, the reforming the social care sector act of 2002 describes the different components of quality and three main dimensions can be identified: 1) The obligation for social care providers to carry out a double evaluation: an internal one carried out by the provider and focused on quality improvement; and an external evaluation (which guarantees renewed authorisation) carried out by an external body; 2) The respect of different basic user right and 3) Multiannual contracts (five years) of objectives and means are signed between social care providers and pricing authorities (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

  • 1.06. Approach to care provision, including sector of ownership

    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 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.

  • 1.07. Care coordination and personalization

    Coordination in the care sector is a longstanding preoccupation of the state and a response to the highly fragmented organization and funding of health, social and the need for ‘medico-social’  interventions in the care field.

    Some level of integration at a local authority level has also been achieved through pathways and networks generally around gerontology and independence loss, as well as regional support networks and local information centres (source: https://halshs.archives-ouvertes.fr/halshs-02058183/document).

    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. 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.

    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).

    Author 2: Alis Sopadzhiyan (LTC Covid profile pending)

  • 1.08. Information and monitoring systems 

    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).

  • 1.09. Care home infrastructure

    Of the 7,502 LTCFs for older people, 50% are public, 31% are not-for-profits, and 24 are for-profit. 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).

  • 1.11. Workforce conditions: pay, employment conditions, qualification levels, shortages

    France reported to OECD that it increased wages in LTC and that this was associated with greater recruitment of workers, longer tenure and lower turnover. However, wage increases need to be financed and regulated. Otherwise, wage increases that are not matched by increases in resources lead to increased workload and duties. One-third of institution-based LTC workers were temporary agency workers (source: https://www.oecd.org/fr/publications/who-cares-attracting-and-retaining-elderly-care-workers-92c0ef68-en.htm).

    The distribution of different workforce roles is as follows:  domiciliary care nurses (SSIAD), 117 093 in 2014; domiciliary care workers, registered with NFPs and public organisations, around 535 000 in 2011; private companies for domiciliary care employ approximately 4% of the workforce. There has been limited success with attempts at professionalisation to improve quality in delivery. There was no increase in staff to resident ratios in care homes between 2011-15 despite increase in demand. Diplomas have been developed over the years, and 62% of workforce has some level of qualification, but despite these workers 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).

    Due to the limited attractiveness of the sector, especially 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).

  • 1.14 Pandemic preparedness of the Long-term care sector

    Following the 2003 heatwave France had mandated the use of ‘blueprints’ in LTC facilities (and other healthcare settings) to prepare against extreme health events, and these were triggered in February 2020. 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).

PART 2 – Impacts of the COVID-19 pandemic on people who use and provide Long Term Care
  • 2.01. Impact of the COVID-19 pandemic on the country (total population)

    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.

  • 2.02. Deaths attributed to Covid-19 among people who use and provide Long-Term Care

    France first published official death estimates for people in care homes on March 31, 2020. Deaths linked to COVID-19 among care home residents had been stable from the end of July until the week ending September 20, when they started to increase again.

    The most recent numbers published by the Ministry of Health on April 1, 2021, 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. Deaths among care home staff are not reported in the bulletin. 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 6.10% of all the available beds (Source: https://www.insee.fr/fr/statistiques/3676717?sommaire=3696937).

  • 2.04. Impacts of the pandemic on access to health and social care services (for people who use Long-term Care)

    Both senate and National Assembly commissions report significant issues around access to services, both in health and social care, for service users in LTCFs and in receipt of domiciliary care. 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.

    In early 2021, a total of 47,428 cases were recorded among social care workers, of which at least 17 have died (URL: https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf)

  • 2.05. Impacts of the pandemic and measures adopted on the health and wellbeing of people who use and provide Long-Term 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. 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.

PART 3 – Measures adopted to minimise the impact of the COVID-19 pandemic on people who use and provide Long-Term Care
PART 4 – Reforms to strengthen Long-Term Care systems and to improve preparedness for future pandemics and other emergencies
  • 4.01. Reforms to address Long-Term Care governance

    A fifth pillar of social security is being created around long-term care insurance. Social care policy (termed policy of ‘independence’) 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 regional authorities for the disabled (Maison Departementale des Personnes Handicapees) and local regional authorities for independence (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.

    Author 2: Alis Sopadzhiyan (LTC Covid profile pending)

  • 4.02. Reforms to the Long-term care financing system

    An EU report (2021) noted that 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 Health System, dedicated to the loss of autonomy of older people and people with disabilities, with EUR 1 billion funding.

    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.

    Author: Alis Sopadzhiyan (LTC Covid profile pending)

  • 4.03. Reforms to develop or improve Long-Term Care data and information systems

    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).

    Author 2: Alis Sopadzhiyan (LTC Covid profile pending)

  • 4.05. Reforms to address Long-Term Care workforce recruitment, training, pay and conditions

    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, which was a consultation of all medical and social care stakeholders over 2020 to contribute to recovery of the health and care sectors and build resilience, a number of measures were taken to revalorise health and care staff.

    To increase the attractiveness of the care home sector as a route of employment, care worker pay was reviewed in 2020 and increased by 183€ per month.

    Increased salary rates for domiciliary care workers in the public sector will start from October 1st 2021 and will represent a 13-15% increase in pay.

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

    Author: Alis Sopadzhiyan (LTC Covid profile pending)

  • 4.06. Reforms to improve support for unpaid carers

    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).

  • 4.08. Reforms to strengthen community-based care

    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.

  • 4.09. Reforms to improve care homes, including new standards and building regulations

    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, 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.

    Author 2: Alis Sopadzhiyan (LTC Covid profile pending)

Printable version of this country profile:

https://ltccovid.org/country/france/

To cite this report (please add the date in which the document was accessed):

Oung, C. COVID-19 and the Long-Term Care system in France. In: Comas-Herrera A., Marczak J., Byrd W., Lorenz-Dant K., Pharoah D. (editors) LTCcovid International Living report on COVID-19 and Long-Term Care. LTCcovid, Care Policy and Evaluation Centre, London School of Economics and Political Science. https://doi.org/10.21953/lse.mlre15e0u6s6


Ongoing research projects on COVID-19 and Long-Term Care in France:

https://ltccovid.org/completed-or-ongoing-research-projects-on-covid-19-and-long-term-care/?_country=france

Acknowledgement and disclaimer

This report has built on previous LTCcovid country reports and is supported by the Social Care COVID-19 Resilience and Recovery project, which is funded by the National Institute for Health Research (NIHR) Policy Research Programme (NIHR202333) and by the International Long-Term Care Policy Network and the Care Policy and Evaluation Centre at the London School of Economics and Political Science. The views expressed in this publication are those of the author(s) and not necessarily those of the funders.

Copyright: LTCCovid and Care Policy and Evaluation Centre, LSE