Since 2015, LTC is governed through three separate legal acts: the Long-term Care Act (WLZ 2014), the Social Support Act (WMO 2015) and the Health Expenses Act (Zvw 2008). As a result, there are different rules and funding streams for care-related (LTC insurance), social support related (municipalities) and health and nursing related (health insurance) services. LTC is needs assessed, access to institutional care is not means-tested, however residents have to contribute to their board and lodging- co-payments depend on their income (Bruquetas-Callejo and Böcker, 2021).

References:

Bruquetas-Callejo, M., Böcker, A. (2021) Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future MC Covid 19 Working Paper 11/2021

The population of The Netherlands is around 17.4 million (source: World Bank) and the median age is 43.3 years (source: Worldometres).

In 2021, 20.5% of the total population of The Netherlands was over age 65 and just under 5% was over 80 (source: Statista).

The Ministry of Health, Welfare and Sport is responsible for health and all aspects of long-term care (LTC). This includes care homes, social care and nursing care. Since 2015, community care has been devolved to private insurers and municipalities. Regional care offices contract with (WLZ and ZVW) providers and have a responsibility to ensure that there are sufficient services to meet demand. These offices are run by one private care insurer who represents all care insurers active in the region. Municipalities are responsible to provide services under the WMO and have incentives to reduce costs (Bruquetas-Callejo and Böcker, 2021).

References:

Bruquetas-Callejo, M., Böcker, A. (2021) Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future MC Covid 19 Working Paper 11/2021 

Public expenditure on LTC as percentage of GDP was estimated to be 3.5% in 2016, more than twice the European Union average of 1.6% (EU Commission, 2018). Seventy five percent of spending is allocated to residential care. Private expenditure on LTC (co-payments and out of pocked payments) is relatively low. However, in residential care, residents have to contribute to their board and accommodation. Co-payments have increased considerably for those with higher incomes. Cash for care has been a recent addition for people receiving community care, but in 2016, only 4.7% of recipients of home care aged 65 and over had a personal budget. Benefits are universal but needs tested. There has been a marked shift over time from institutionalisation to community care, with substantial involvement from patient and client organisations. There has been another more recent shift from collective (state) responsibility to individual responsibility and self-reliance. Involvement of unpaid carers, especially families, is now part of the official policy. This however goes against the widespread view that the state should take responsibility for older people in need of care. It is also recognised that this shifts the burden of care back to women (Bruquetas-Callejo and Böcker, 2021).

References:

EU Commission (2018). The 2018 Ageing Report Economic & Budgetary Projections for the 28 EU Member States (2016-2070)

Bruquetas-Callejo, M., Böcker, A. (2021) Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future MC Covid 19 Working Paper 11/2021 

The Netherlands has been experimenting with various integrated care initiatives over the past years (source: WHO | World Health Organization).

Care homes are distinguished by whether they have an WLZ (Wet langdurige zorg, LTC) accreditation. These mostly include nursing homes and residential care homes with a nursing department. Care homes without a WLZ accreditation do not provide nursing care or medical treatments, but are residential homes that provide small-scale elderly housing and apartments linked to nursing homes, in which additional care can be provided as needs increase. In addition, there are private care homes for more affluent residents who contribute more to the costs of housing and facilities (such as entertainment). There is also small-scale housing where people pool their WLZ cash (provided as a personal budget) and which are self-organised or provided by entrepreneurs. Nearly 114,000 people aged 65 and over live-in residential care and nursing homes (Bruquetas-Callejo and Böcker, 2021).

References:

Bruquetas-Callejo, M., Böcker, A. (2021) Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future MC Covid 19 Working Paper 11/2021 

The government provides subsidies for people wishing to go into LTC training. Dual career track is available for nurses working in general care and geriatrics. The country has developed stress management/coaching programmes on healthier work environment and prevention of work-place accidents for LTC centres to help decrease absenteeism (OECD, 2020).

References:

OECD (2020) Who carers? Attracting and Retaining Care Workers for the Elderly.

In the Dutch long-term care system, the rights of clients have been strengthened by legislation. The ‘Participation by clients of Care Institutions Act (WMCZ)’ mandated every care organization to have a client advisory council: whose members are recruited from the users of the care organization and who will represent them. Care organisations assist client councils by providing resources such as office space, meeting rooms, budget, etc. More specifically, client councils have the legal rights to have meetings with management about organisations’ policy, to receive information, to request an investigation into mismanagement, to be consulted, and to consent. The right to be consulted permits client councils to give their advice regarding issues on changing the aim and policy of the organisation, merger with another organisation, and financial matters, but the management can disregard the advice provided by councils. The right to consent means that client councils have to approve plans concerning issues that affect the daily living of clients (e.g. in relation to diet, safety, recreation and leisure, hygiene, the quality of healthcare for clients, changes to the complaints procedure. The care organisation management cannot perform changes regarding these issues without approval from a relevant client council (Zuidgeest et al. 2011).  In 2019 the earlier WMCZ act was replaced by the act ‘WMCZ 2018’, which aimed to expand the rights for client councils to truly participate in organisational decisions regarding matters that influence the clients’ daily lives. Client councils have the right to consent to these decisions as well as the right to provide solicited and unsolicited advice (Kruse et al 2020).

References: 

Zuidgeest, M. et al. (2011). Legal rights of client councils and their role in policy of long-term care organisations in the Netherlands. BMC Health Service Research  doi: 10.1186/1472-6963-11-215

Kruse, F., van Tol, Vrinzen, C., van der Woerd, O., Jeurissen, P. (2020). The impact of COVID-19 on long-term care in the Netherlands: the second wave. LTCcovid report 

The Netherlands had a national pandemic action plan in place as well as various obligations on hospitals and others to have disaster relief plans. However, these were seen as insufficient. It was also criticised that the government had ignored recommendations provided by experts following the 2014 Ebola outbreak and the 2018 influenza epidemic. The national plan had specific appendices for care and nursing homes (Bruquetas-Callejo and Böcker, 2021). Most Dutch Long-Term Care organisations have an Infection Prevention and Control committee (van Tol et al., 2021).

References:

Bruquetas-Callejo, M., Böcker, A. (2021) Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future MC Covid 19 Working Paper 11/2021

van Tol LS, Smaling HJA, Groothuijse JM, et al COVID-19 management in nursing homes by outbreak teams (MINUTES) — study description and data characteristics: a qualitative study BMJ Open 2021;11:e053235. doi: 10.1136/bmjopen-2021-053235

During the first wave of the pandemic, Southern regions of the Netherlands were hardest hit, with Carnival celebrations being one of the main catalysts. The second wave started in September 2020, and by November was most pronounced in the West, including in the large urban centres Amsterdam, Rotterdam, and the Hague. An overview of the first year of the pandemic is available here.

Sources: https://ltccovid.org/wp-content/uploads/2020/11/COVID-19-Long-Term-Care-situation-in-the-Netherlands-_-the-second-wave-25-November-2020-2.pdf.

During the first wave, the National Institute for Public Health and the Environment (RIVM) estimated that about 40% of nursing homes had experienced outbreaks. By May 15, 2020, about 7% of residents in nursing homes had been infected and 2% had died. A report published in November 2020 noted that approximately 50% of all COVID-19 related deaths during the second wave were residents of nursing homes.

As of March 6, 2021, there had been 8,446 COVID-19 related deaths of care home residents. Accounting for 51% of the total COVID-19 deaths in the Netherlands. These numbers are an underestimation of the actual COVID-19 deaths because not all those who died due to COVID-19 will have been tested (especially at the beginning of the pandemic). Only people over 70 years of age are included in these statistics.

As of April 25, 2022, there are 10,867 COVID-19 related deaths of care home residents and 22,227 deaths in the Netherlands overall (Source:https://coronadashboard.rijksoverheid.nl/landelijk). Thus care home residents account for 48.8% of the total COVID-19 deaths. The Netherlands has approximately 125,000 care home residents, so the deaths represent 8.7% of residents.

Statistics Netherlands (CBS), a governmental organisation, provides weekly updates on observed mortality. They distinguish the mortality figures by long-term care users and age. They also provide expected figures based on the previous 5 years to estimate excess mortality. These figures show that there has been 9.9% excess mortality (observed-expected/expected) among long-term care users since the start of the pandemic to the end of January, 2022, compared to 8.5% excess mortality among the wider population (outside long-term care).

Nursing homes (usually running waiting lists) now have empty beds because people are reluctant to move into a home, in response to the visiting ban, while other nursing homes had to implement temporary bans on new admissions (Sources: https://drive.google.com/file/d/1Ji-iDCjC-8EbBpV0dW_xlz780uvU7F–/view; https://ltccovid.org/wp-content/uploads/2020/11/COVID-19-Long-Term-Care-situation-in-the-Netherlands-_-the-second-wave-25-November-2020-2.pdf). However, questions have been raised about the access to health care for Covid-19 patients in nursing homes (Source: https://ltccovid.org/wp-content/uploads/2020/11/COVID-19-Long-Term-Care-situation-in-the-Netherlands-_-the-second-wave-25-November-2020-2.pdf).

During the first wave, people receiving care in the community who also had family support experienced a reduction or suspension of services. This approach was changed in the second wave, where home care could only be reduced following a consultation with the person with care needs. However, there were instances, such as when there was a lack of staff when services were temporarily reduced.

Efforts have also been made to continue day care, by moving services, where possible, online. Technological interventions have received increased government subsidies. During the second wave day care activities were largely not reduced, but a number of difficulties around ensuring the safety of people with LTC needs and staff were identified (Source: https://ltccovid.org/wp-content/uploads/2020/11/COVID-19-Long-Term-Care-situation-in-the-Netherlands-_-the-second-wave-25-November-2020-2.pdf).

Impacts on people living with dementia

A qualitative study involving semi-structured interviews with family and professional carers of people with dementia found that, for people with dementia, social distancing measures resulted in a deterioration of physical health and that the impact on emotional state and behaviour depended on the stage of dementia. The authors were not able to establish if the observed cognitive decline was due to the usual disease progression or to under stimulation due to social distancing measures.

The study found that the negative impacts were more pronounced for people living in the community with more severe dementia, and in nursing homes for people with mild to moderate dementia, the authors attributed this to the loss of ability to carry to carry out meaningful activities that provide a sense of purpose (Smaling et al., 2022).

Another study focused on the changes in behaviour considered challenging among care home residents, as reported in a survey of 199 nursing home practitioners. It found that there were reports of both increased and decreased behaviours considered challenging by staff, with a slightly higher proportion of increase. While staff attributed both increased and decreases to the ban in visits in place at the time, the most negative effects were attributed to residents not being allowed to go outside, being made to stay in their rooms and changes in organised activities, with those with mild to moderate dementia having been most affected (Leontjevas et al., 2021). A further analysis of that data explore the views of practitioners on the effects of reductions in stimuli on behaviour. The study distinguished between targeted stimuli (such as planned recreational activities) and unplanned stimuli (for example spontaneous noise in corridors). Practitioners reported that, for residents with advanced dementia and those with psychotic and agitated behaviours reductions in untargueted stimuli were beneficial, as well as the the adjustments made to daily activities. In contrast, for people without dementia and those with depressive and apathetic behaviour the reduction in stimuli was considered to have had negative effects. The study concludes that it is important to adopt approaches more tailored to the needs of individual residents in terms of the right balance between stimuli and tranquility. Practitioners supported the the idea of creating separate environments within care homes with different levels of stimulation for residents with different needs (Knippenberg et al., 2022).

Impact of physical distancing on vulnerable people needing care

A study by de Vries et al. (2022) on the impact of physical distancing on vulnerable people (including people with learning disabilities, mental health problems, older people with care needs living in the community and in residential care, as well as carers) noted a range of experiences,  from relative calmness to loneliness and loss of perspective. For those with small social networks, the loss of  care professionals and informal carers in their daily life during the pandemic meant the loss of a vital part of their social networks. Overall, the loss of social contact for a longer time was linked to low quality of life or motivation for life.

References:

Knippenberg, I.A.H., Leontjevas, R., Nijsten, J.M.H. et al. Stimuli changes and challenging behavior in nursing homes during the COVID-19 pandemic. BMC Geriatr 22, 142 (2022). https://doi.org/10.1186/s12877-022-02824-y

Leontjevas R., Knippenberg I.A.H., Smalbrugge M., et al (2021) Challenging behavior of nursing home residents during COVID-19 measures in the Netherlands, Aging & Mental Health, 25:7, 1314-1319, DOI: 10.1080/13607863.2020.1857695

Smaling HJA, Tilburgs B, Achterberg WP, Visser M. The Impact of Social Distancing Due to the COVID-19 Pandemic on People with Dementia, Family Carers and Healthcare Professionals: A Qualitative Study. International Journal of Environmental Research and Public Health. 2022; 19(1):519. https://doi.org/10.3390/ijerph19010519

de Vries, D., Pols, A., M’charek, A. and van Weert, J. (2022) The impact of physical distancing on socially vulnerable people needing care during the COVID-19
Pandemic in the Netherlands, 6(1-2): 123–140, International Journal of Care and Caring, DOI: 10.1332/239788221X16216113385146

A report from November 2020 indicates that unpaid carers in the Netherlands have experienced more pressure and stress in their caring role since the COVID-19 pandemic.

Impacts on family carers of people living with dementia

A qualitative study involving semi-structured interviews with family and professional carers of people with dementia found that family carers of people living dementia found difficult to cope with visiting restrictions, experienced anxiety regarding safety and had higher carer burden.

Relatives of people living in care homes reported that video calling and window visits were difficult as people with dementia often found it difficult to communicate in this way or use equipments, but relatives stated that this was better than no communication. They also worried that their relatives with dementia would no longer recognise them when the restrictions were lifted. Their carer burden was reduced, but they felt sidelined as they were no longer able to continue providing care.

Carers of people living in the community tried to keep the “bubble” around the person with dementia small. They worried about professional carers not adhering to safety measures and experienced higher care burden.

References:

Smaling HJA, Tilburgs B, Achterberg WP, Visser M. The Impact of Social Distancing Due to the COVID-19 Pandemic on People with Dementia, Family Carers and Healthcare Professionals: A Qualitative Study. International Journal of Environmental Research and Public Health. 2022; 19(1):519. https://doi.org/10.3390/ijerph19010519

The high numbers of deaths in nursing home affected the occupancy rate of homes which led to loss of income especially of those hardest hit by the pandemic. The government sought to address this through payments for providers (Source: https://ltccovid.org/wp-content/uploads/2020/11/COVID-19-Long-Term-Care-situation-in-the-Netherlands-_-the-second-wave-25-November-2020-2.pdf).

An OECD paper and other sources indicated that the Netherlands has experienced staff shortages during the various waves of pandemic. To address these, the country provided financial help to LTC facilities to recruit unemployed or former LTC workers, and provide financial help to LTC facilities to recruit students. LTC facilities also received financial support that they could use independently; including for stafff recruitment. Moreover, a pool of volunteers for emergencies was activated to boost staff at the start of the pandemic.

However, according to a recent report (February 2022) by The Federation of European Social Employers, The Netherlands has experienced an increase of between 1 – 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.

An EU report noted that several programmes were set up in 2017 with an aim to improve integrated delivery of care and the matching of care to needs.

An EU report (2021) noted that the Netherlands implemented numerous measures in 2017, including: improved working conditions; better protected contracts (e.g. open-ended contracts, flexible working time, leave); better matching of supply and demand. The government programmes also focus on improving the attractiveness of the sector via image campaigns as well as other measures improving working conditions and training.

The country aims to focus research on pandemic-related issues (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).