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).

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)

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€.

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.

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).

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).

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).

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).

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).

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 

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).

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.

Data 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).

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.

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.

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

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

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.

An expert scientific group was set up on March 12, 2020, and a first lockdown was announced on March 14 (Source: https://www.covid19healthsystem.org/countries/france/livinghit.aspx?Section=5.1%20Governance&Type=Section). 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.

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.

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)

An investment of €6bn was made in July 2020 to enable renovations and technology upgrades across the health and social care sectors (Source: https://www.lefigaro.fr/flash-eco/castex-annonce-6-milliards-d-euros-d-investissement-dans-le-systeme-de-sante-20200715). Additionally, €7.6bn was secured for an increase in base salary for workers in public hospitals and care homes of €182/month, and €160/month in private settings, as well as a revision of salary bands by Spring 2021, maximum hours for overtime, and investment in recruitment policies (Source: https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf).

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 a Covid bonus going up to 1,000€ in late 2020. Staff working in long-term care facilities were also entitled to a bonus of up to 1,500€.

More recently, the government has 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).

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).

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. 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). 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.

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). 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).

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).

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 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.

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)

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, 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)

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, 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.