France

Demographic information (INED, 2011)

• Inhabitants: 65,036,000 (incl. overseas population)
• No. of citizens 65+:  10,952,000
• No. of citizens 75+: 7,200,000
• No. of people with long-term care needs: about 4,100,000

Characteristics of health, social and long-term care delivery

France is a central state divided 21 regions with a “command and control” type of governance with a strong executive power and a weak parliament. The French LTC system (called medico-social) and the health care system are still separately organised, regulated and funded. Another specific characteristic of the French LTC system consists in the “age division” of the population with disabilities into two groups: Persons less than 60 called “handicapped” and those above 60 (and called “dependant”). This division acts as a barrier with two specific policies and provider organisations for each population. So even if measures aiming at keeping elderly persons in their usual home environment had been on the social policy agendas for more than 50 years (Rapport Laroque,1962), until the beginning of 2000, no specific policy targeting LTC existed with a restricted access to formal home care services for older people with care needs.

After a five-year experiment of a care attendance allowance scheme dedicated to persons aged more than 60, a dramatic change happened in July 2001 when a more generous new scheme called (APA, Personal Autonomy Allowance) was passed into legislation and launched in 2002. This reform was followed by a series of laws, passed in a five-year period aiming at considering the LTC system as a whole, with a strong focus on home care while simultaneously trying to reinforce the level of staffing and management of nursing homes through enhanced funding.

The law for ‘the equality of rights and opportunities, participation and citizenship of disabled persons’ voted on 11 February 2005 was considered as marking a genuine conceptual turning point in that it stressed on the necessity to create a converging process in order to reconcile separate policies regarding disability issues and called for a new LTC insurance scheme (called “Fifth risk”) that would apply to any person with LTC needs, irrespective of age. Since 2004, local political levels (general councils) have received major responsibilities in the supervision of LTC providers. Following the set up in 2005 of a national agency (CNSA) for supervising policies for people with care needs at national level, another national agency (ANESM) was put in place in 2007 to reinforce quality methods and boost the professionalisation of all LTC specific providers. Even though the commitment for publicly funded health and social services remains strong, services are more and more provided by a mixed economy of public, private and voluntary sector providers. Presently, the issue on how to optimise the mix of complementary private with a basic public LTC insurance scheme is high on the political agenda.

Background information on key-issues

Quality assurance and quality management in LTC

(...) The way quality in the LTC system is managed depends not only on specific concepts and methods regarding quality for this sector but also on the structure of the LTC system and its relationship with the health system and the society at large. It appears that quality regulation should be examined at least at two levels (state and local political level) but also according to the fact that different quality regulation systems apply to the health and social sectors. Because of the tradition of a “strong state control and command”, even at regional or departmental levels, traditional methods of relying on legislation and decrees still characterise the approach of quality control, with a lack of coordination between responsibilities devoted to the various institutional bodies in charge of different types of quality process and measures regarding professional and care agencies. Nevertheless, quality regulation is slowly moving from an approach based on minimum quality standards set at the national level (quality assurance) to a more outcome based assessment, emphasising quality management with more responsibility given to providers levels. And due to the strong orientation given to the client’s perspective, the beneficiary and informal carer’s opinions about quality appears also as a key component of quality assessment (more ...)

The role of informal care in LTC

(...) Informal carers in France are usually understood as “family carers” and this general view fits with data as this last category represents 90% of the former one. Caring for a relative is considered a duty nobody should escape from, a form of “moral obligation”. It is conveyed in the frequent expression “family solidarity” and informal carers are often called “natural helpers”. All surveys show a strong commitment of people for caring for their old relatives. In a 2008 national survey, 82% of the respondents declared that in case of disability, they would not place their relatives in an institution but rather try to help them financially or care for them. This result is in line with results coming from Eurobarometer 2008 (85%). In the vast majority of cases, caring for a relative or a friend takes place at the beneficiary’s or at the informal care’s home and thus tends to be considered as a “private affair”. This does not entail that public authorities should not intervene in this matter. In fact, according to the quoted survey, 52% of the French population shared the opinion that the state should bear main responsibilities for LTC (compared to 16% for the family) in order to organise and fund care provision (more ...)

Governance and financing of LTC

(...) In France, policy regarding disability linked to ageing is the latest extension of the overall social policies embedded in its welfare state. It has gained a large public recognition although this extension has resulted in a superposition of institutions and providers operating within contradictory logics so that this policy is yet not stabilised and largely unachieved. The complex history which explains the design of the actual governance and financing of LTC services state for older people can be summarised as the result of four factors (more ...)