**White House Conference on Aging**

**Global Roundtable on Aging**

December 10 2005

## Innovations in the French Government Policy on Aging

Francoise Forette, MD

On behalf of Philippe Bas, Minister of Social Security, Elderly, Family
and Disabled, I would like, first, to warmly thank the White House
Conference on Aging organizers for allowing International Observers to
participate in these very important working and brain storming sessions.

Indeed, the striking increase in longevity is a new venture of humanity
and a privilege of our nations as long as the aging population remains
healthy and active.

In France, in 2004, 20% of the 62 million inhabitants are 60 years old
and over.

The mean life expectancy at birth is continuously progressing up to
nearly 77 years for men and nearly 84 years for women.

As in other nations, there will be a continuous increase in the 65 +,
75 + and 85 + populations until 2020 but, the percentage of the
population under the age of 60 years, though decreasing, remains rather
high, probably thanks to the maintained fertility ratio at 1.9, one of
the greatest in Europe.

France has one of the highest life expectancy but, - this is
unfortunately another French paradox-, the lowest rate of activity after
60 years of age:7% only of men and 4% of women are still in the economic
circuit, as compared to 27% in the USA, 21% in the UK, 23% in Sweden,
and 51% in Japan.

The predictable consequence will be a dangerous decrease in the worker
to retiree ratio. This low rate of activity after 60 does not find an
explanation in the health status. Indeed, 6% only of the population over
65 years of age, and 2% of the population between 60 and 69 years of age
suffer from dependency due to invalidating diseases**.**

All people do not equally enjoy this excellent health status: There is a
five year difference in life expectancy at 60 between the white collar
and blue collar workers. The part of France where you live may have an
influence: the life expectancy at birth is five year lower in the North
than in the Paris region. But the most important probably is the
activity status. The risk of mortality of unemployed people is for many
reasons, of course, threefold this of the active population.

**The challenge of the French Policy on Aging is to simultaneously
promote health and activity as a long term perspective**.

Indeed, the majority of the population will age in good conditions of
health, personal autonomy and productivity in the sectors where activity
is allowed. But in spite of the progress in prevention, a minority of
persons is and may be victim of age-related diseases leading to
dependency. As well, the oldest old, (90 years old and over) will remain
a frail population whose autonomy is generally assisted.

The Government has therefore a double priority:

1- Promoting high quality Long Term Care systems at affordable costs for
all age groups needing assistance either at home or in institution.

2- Improving social integration and activity of the healthy senior
population.

**I Promoting High Quality Long term care systems**

The mortality rate observed during the 2003 heat wave, (15 000 deaths
mainly among isolated elderly citizens) has certainly increased the
awareness of the population and policy makers on the issues raised by
the aging of the population.

Important decisions were taken to reinforce existing policies, a number
of laws were voted and specific plans established.

> **I ) 1-An Emergency Plan was drawn up**
>
> The objective was a better coordination between the different State
> and regional services, an improvement in the alert systems, a
> reorganization of the emergency services and an attempt to identify
> vulnerable persons and, in particular, isolated elderly who are not
> usual care users.
>
> This plan intends, with specific adjustments, to cope with any
> emergency situation, heat waves or winter cold, terrorist attacks,
> bird influenza etc...
>
> **I ) 2- A law called** **"Solidarity and Aging"** was voted in 2004
>
> By this law, a new branch of the Social Security System was created de
> novo. This branch covers the risk of dependency and offers part of the
> financing of long term care either at home or in institution.
>
> A new Agency was set up called Caisse Nationale de Solidarité pour
> l'autonomie, CNSA.
>
> The agency is financed by the Health System for the medical
> expenditures --the Health system covers all persons living in France-
> and by a new innovative system for the rest of the expenses (9 billion
> € for the 2004-2008 period). The innovative system does not rely on
> general taxation or social-insurance type solution but on the product
> of an extra work day called "Solidarity Day" for all employees and a
> 0.3% tax for the employers. The CNSA is independent of any other
> agency and finances care needs of the dependant elderly and of the
> younger disabled persons. For example:

-   The care costs of dependency ( restrictions in Activity of Daily
    Living and social care such as housekeeping, meals on wheels etc...
    ) either at home or in institutions through a specific allowance
    called APA (personalized allowance for autonomy).There are 850 000
    beneficiaries of this allowance in France.

-   The improvement of services in nursing homes (hiring of nurses, of
    nurses helps, social activities etc\...).

-   New nursing homes or new beds in existing ones (20 000 beds for the
    period 2004-2007).

-   Day care and respite care units.

Besides the public funding provided by the agency, income-related
co-payments are required. Board and lodging are not covered in nursing
homes; users are charged according their ability to pay. Total
expenditures on Long Term Care represent a little more than 1% of GDP
(15 billiard €).

**I ) 3- A Geriatric Specialty** was established in September 2003 and a
Geriatric University Plan was implemented in 2005 in order to double le
number of Professors of Geriatrics from now to 2010. The objective was
to improve the geriatric training of GPs, Specialists, nursing home
physicians, and all professionals taking care of frail elderly.

**Measures are taken to provide a continuum of care** in order to meet
the needs of the elderly in all situations: Geriatric acute care units
are being set up in all hospitals with emergency wards, the number of
rehabilitation beds is increasing and the hospital long term care units
for patient with unstable severe chronic diseases will be better staffed
and equipped. Networks between hospital care and community care are
strongly recommended and financed.

**I) 4- Shifting the balance toward home-based care is promoted by the**
**government** to enable older citizens who need assistance to remain in
their own homes. Home services are expanding to give a choice to the
older persons and the number of recipients is increasing by 4000 each
year. The contribution of a family member or other informal carers is
often necessary and services to support carers include psychological
assistance, specific information on care giving, day care centres and
institutional temporary respite care.

I)  **5-** **An Alzheimer Plan was implemented** to cope with the
    age-related increase in the prevalence of Alzheimer's disease and
    related disorders. These diseases represent 70% of the causes of
    institutionalisation and 72% of the requests of the APA allowance.

The Alzheimer's Plan is aimed at raising the rate of early diagnosis
(presently at 50%) by increasing the number of Memory Clinics (263 up to
600) and the number of Resources and Research Memory Centres (24 up to
40). The second objective is to train GPs, professionals, patients and
caregivers .and to support families and informal carers (Specific
Alzheimer day care centres and respite care). Another important
objective of the Alzheimer Plan is to better fund Research in all
aspects of Alzheimer's disease.

As a whole, these new laws and plans should greatly improve the
condition of the frail and dependent elderly

**II** **Changing the image of aging and promoting the social
integration of the healthy senior citizens in the community and the
workforce of the country is another priority of the Minister's policy**

The goal is to ensure people's future financial security, health and
quality of life, enabling them to be productive members of society
throughout their lives.

> Key objectives are being pursued:
>
> \- Promoting Health prevention throughout life.

-   Reforming Employment Policy after 55 years of age.

-   Changing the image of aging and favouring relationships between the
    generations.

# II ) --1 Health promotion and prevention

Most of age-related diseases may be related to modifiable risk factors
and then accessible to prevention. Prevention is still successful after
the age of 60 but it should be started before the age of 20 years by
promoting healthy lifestyles.

A National Program: "Aging Well" has been launched in 2005, based on
Nutrition, Physical Activity and social integration. This program is to
be implemented locally by municipalities.

A working group is considering a systematic comprehensive geriatric
assessment at the age of seventy to detect all risk factors likely to
lead to disabling diseases.

# II ) 2- Reforming Employment Policy after 55 years of age 

Reforms aiming to improve the incentives and opportunities for older
people to play a part in the labour market for longer are in process. A
comprehensive strategy is thought over to tackle the various
disincentives and barriers to employment facing older workers. This
requires action by both the public authorities and social partners in
the following areas:

-   Reform retirement and social welfare systems to strengthen work
    incentives (progressive retirement, new contracts, simultaneous
    working/retiring)

-   Encourage change in attitudes of employers and workers

-   Adapt employment protection rules to promote employment of older
    workers

-   Promote training for upgrading skills and acquiring new ones.

-   Improve access to high-quality employment services for older job
    seeker

-   Improve working conditions

**II ) 3- Changing the image of aging and favouring relationships
between the generations**.

Healthy and productive ageing brings with it enormous individual,
economic and societal benefits. It bears an optimistic perception of the
longevity revolution in our societies. This positive image of ageing
must be spread over the media, papers, magazines, schools and university
programmes. The society must stop considering the demographic evolution
as a burden while it is an opportunity for all generations living
together.

The government intends to favour all intergenerational experiences:
Skill sharing, tutoring, and volunteering mixing young and elderly
people, multigenerational projects creating suitable work for older and
younger people in a wide range of forms of employment. Some experiences
of "integrated lodging" including young parents and children, disabled
elderly, healthy retired persons and common services for all, show how
it may generate close relationships between the generations.

**In conclusion**, the ethical challenge of the French government is to
simultaneously organize outstanding care for the frail elderly and to
promote healthy and productive ageing in order to allow all people,
regardless of their age, to enjoy fulfilling lives, at home, at work and
in their communities.

Contact: Françoise Forette, MD, Professor

Special Adviser on Aging to the Ministry for Social Security, Elderly,
Family and Disabled

Ministry of Health

14 avenue Duquesne, 75007, Paris, France

e-mail: francoise.forette@sante.gouv.fr