project 5 - residential homes

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Feasibility and opportunity to develop astandardisation work programmeconcerning residential homes for olderpeople Food Industry and Health Care

Department

Final Report

Submitted by

AFNORAssociation Franaise de Normalisation

July 2008

Sara LA TOUR

AFNORTl: +33 (0)1 41 62 82 94Fax: +33 (0)1 49 17 90 [email protected]

SA/CEN/ENTR/371/2006-27 Project N5

AFNORAssociation Franaise de Normalisation

11 rue Francis de Pressens93571 LA PLAINE SAINT DENIS CEDEX

Tel:33 (0) 1 41 62 82 47Fax:33 (0) 1 49 17 90 00


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Executive Summary

This final report stems from a feasibility study contract on residential homes for older people within theframework of mandate M/371 addressed to CEN by the European Commission. The objective was toexplore the possibility of European standardisation for the Residential Homes for Older People.

The feasibility study has been conducted by AFNOR according to a five-step methodology. The resultshave highlighted that residential homes for the older people services are challenged by demographicchanges (shift towards homecare, availability of services, availability and competence of the work force,quality of the services, etc.). The results have also put forward that European standardisation wasperceived as a relevant means to meet those challenges either by users and by providers and somerecommendations were proposed by stakeholders.

Chapter one is reminding the policy context and the rationale for this feasibility study on residential homesfor older people. The population of older and dependant European people may increase of 72%

1.

Because there is a prevalence/higher incidence of disease and incapacity/disability in older agegroups, Addressing multiple medical and social care needs becomes an issue for residential homes.The services offered in residential homes for older persons ought to be accompanied by thedevelopment of different types of services, increasingly adapted to the treatment of numerouspathologies.

The admission of older people to a residential home is an important step in their life. For them and theirfamily, choosing an establishment is not an easy task. Being informed about the services delivered byestablishments, comparing them and assessing the quality of services provided is essential in making aconfident decision.

Different types of structures currently exist, proposing varied services, with variable quality levels. Thiscomplicates the comparison of the services provided by these establishments for the elderly persons andtheir families.

That is why clarifying the service commitments of these establishments, associated with a definition of theperformance level of the services, would facilitate the creation of common references in Europe.

Developing European standards on services provided by residential homes for older people may beconsidered as a tool, in addition to the already existing national legislation concerned with these matters,to allow the enhanced protection of the rights of people all over Europe and to defend ethical principles, toavoid potential abuses from service providers and to ensure transparency on the quality of the servicessupplied, to develop professionalism in this field of activity, and finally, to promote cross-border circulationof persons in Europe.

Chapter 2 describes the methodology and the tasks completed at each step. Data has been collectedthrough NSB, questionnaires and in depth-interviews. Finally, a seminar has been organised and mainstakeholders had the opportunity to debate on the relevance of European standardisation in the field ofresidential homes for older people and then to propose recommendations for European standardisationwork.

During the step 1, research of information and preliminary data collection has been completed. Thepurpose of this step was to collect information from each country about: the local markets of services toresident persons, existing practices, existing regulations, standardisation background, the strategies of theservice providers. The conclusion of this step is that there was a real interest of the participating countriesto participate in some European Standardisation work if any. However, some more discussions on thescope were seen as necessary in order to really take into account the national particularities of eachcountry (for instance, in some countries, this field of activity is nationally regulated, which is not in itself anobstacle but would need further discussions).

During Step 2, the detailed investigation, The purpose of this step was to go further in gathering ofinformation on the needs and expectations of stakeholders, in getting accurate information on the sector ofresidential homes for older people, and finally in exploring the opportunities for the development ofstandardisation projects in this area. Step 2 has allowed getting a precise picture of the issues of the sector

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with different sources of information and different methods. It can be noted that the views and the concernsof stakeholders grasped through questionnaires and interviews were always coherent with the results ofEuropean and national reports and studies.

The aim ofstep 3 was to propose a draft document presenting the various positions of the stakeholders onthe standardisation proposal in the field of residential homes for older people, and a synthesis. The resultshighlighted that there were a lot of discrepancies across European countries in the availability and quality ofthe services and that there is a lack of human resources that was impacting on the quality of the service;that some more user-oriented competences were needed ; and that there was a need to clarify theusers/providers relation (more transparency and more power for the user for instance).

The aim ofstep 4 was to organise a debate between the stakeholders (NSBs and other partners) in orderto assess if developing a European Standard in the field of residential homes for older people was arelevant means to contribute to the performance of the services in this sector. The seminar has been anopportunity to put forward the degree of agreement concerning the relevance of European Standardisationfor the residential homes for older people sector. It has also allowed to collect the suggestions andrecommendations of stakeholders concerning the way to meet these needs. Most of thoserecommendations were concrete proposals for some European standardisation work, while some otherwere rather promoting European directives in the field of services or not supporting the idea of Europeanstandardisation at all.

Step 5 is the elaboration of current document. The objective of this document is to report the main stepsand tasks completed during the feasibility study, to present the conclusions and recommendationsstemming from the feasibility study and finally, to focus on the operational steps to implementrecommendations and associated next steps that can be taken afterwards.

Chapter 3 gives an overview of the residential homes for older people sector and presents the maineconomic and social issues of the sector as well as the policy and regulatory context. This sector is underpressure considering the demographic issue, the associated cost and the probability that there could besome lack of resources to face all the future needs.

The market of residential homes for older persons is part of the long-term care services sector and havehistorically been funded by public sector. The issue of reducing fiscal deficits has brought some memberstates to introduce competitive elements in the provision of services and involve private service providers.

More and more, residential settings for older people tend to be more and more intertwined and integratedwith home care with more prevalence of the latter across European countries.

In addition, the general trend concerning consumers preference for a place to live is to choose home careor family care, even if there are national differences in this choice, like for Norwegians, for instance, whoclearly prefer residential settings when they cannot anymore care for themselves.

One of the main economic and social issues of the residential homes for older people services sector is toface the growing demand and make sure there are enough resources to purchase and to deliver thoseservices, including the availability of a qualified workforce. Moreover, this sector has to prepare itself tomeet the more complex needs of older people in the residential homes. Finally, as the public sector isdecentralising and outsourcing more and more services in this sector, another important issue is toreinforce transparent contractual relationships across many different services providers.

At European level, after the adoption of the Strategy of Lisbon in March 2000, social priorities of theEuropean Community were focused more on Older People, than in the past. European community,through the Open method of coordination allows the EC to work in this domain by promoting a strongcooperation between member states on employment, social welfare (pensions), fight against the poverty,social exclusion, education and recently in the field of the long-term care.

2

At National level, the strategy concerning long-term care for older people is also reviewed with anoverview of the current legislation and public policies related to long-term care in European countries.Some of those recent legislation and public policy are about reorganisation of health and social sector(Denmark) including the reinforcement of quality of services. Some are about reinforcing the home care

2 The Lisbon Treaty (2007/C 306/01 and Commission of the European Communities (2008). Communication from thecommission to the European parliament, the council, the European economic and social committee and the committee of theregions. A renewed commitment to social Europe. Reinforcing the Open Method of coordination for Social Protection andSocial Inclusion


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trend, to make home care more accessible (24 hour care at home policy in Austria; Free choice of homehelp in Denmark; The Borloo Plan in France) or aim at supporting family care for dying person (Familyhospice Sabbatical in Austria).

A review of the national standards in this sector of activity shows that most health and social care servicesstandards concerns are addressed via management guidelines and very few (Germany, Italy, Spain, andFrance) deal with service requirements based on users' expectations and the quality of services. TheGerman standard however targets different customers (private residences with assisted living) and Italy isworking more specifically on nursing homes. France proposes a more generic document on servicerequirements. All standards concerning residential homes services are elaborated at national level untilnow, the only European initiative that will include all member countries being the Austrian initiative onsheltered housing services (April 2008). This initiative shows an existing need for a European answer tosome problems traditionally answered at national level.

Chapter 4 focuses on the needs and recommendations concerning European standardisation. The firstsection describes the stakeholders needs while the second one illustrates their position towards EuropeanStandardisation. A third section reports all the concrete recommendations for European standardisationmatters made by stakeholders.Stakeholders, users and providers, have expressed their views at several steps, through questionnaires,in depth interviews and European seminar debate. Their concerns were about the lack of human

resources in the field of residential homes and the need to have some competent staff. They were reallyinterested in clarifying the contract relation and confer more transparency to the relation betweenproviders and users and need of some tools (guidelines on geriatric assessment, on information to beprovided to users, on code of ethics and conduct) that Europeans standardisation would be able to help tobuild.

For stakeholders, the long-term care issue can be addressed at European level as well. Most of them(services providers and users representatives) have acknowledged the importance of sharing goodpractices and have a European strategy for addressing their needs.

Among the main reasons why European standardisation should be conducted in the field of residentialhomes for older people, they have pointed out the mobility of workers and the cross-border services in theresidential homes for older persons sector. More over, it is perceived as positive that countries share theirbest practices and help each other to obtain a better quality of care.

However, European standardisation work would have to take into account some elements that could makeharmonisation more difficult (different life styles and economic levels in the European countries: verydifferent material conditions and cultural backgrounds; the specificities of every region (rural / city) orcultural background (languages, family models, management of home care, etc.).

Recommendations put forward by stakeholders for the Residential Homes for Older People servicessector are concerning:

Terminology and classification

Process of service provided to older people

Characteristics of the service

Guidelines on social life and life environment in residential homes for older people

Training and competenceStandardisation documents about means (guidelines documents to support theimplementation of a good quality service)

Chapter 5, as a conclusion, confirms the concern of all stakeholders for improvement of quality of servicesin residential homes for older people. It also confirms that most stakeholders find Europeanstandardisation relevant in order to meet those needs and report their recommendations for futureEuropean standardisation work in the field of Residential Homes for Older People. Finally on the basis ofthe conclusions of the study and the stakeholders recommendations, this report recommends theEuropean Commission and the European Committee for Standardisation (CEN) three actions and theassociated next steps that can be taken in order to implement them. Those recommended actions are theimplementation of multi-stakeholders group, the elaboration of European standards within a CEN technicalcommittee dedicated to long-term care and finally some communication in order to promote the role of

European standardisation.


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The feasibility study has been a fantastic opportunity to gather a lot of information and to put togetherdifferent stakeholders from several European countries. A common aim was motivating them: theimportance of considering the quality of services in Residential Homes for Older people.

Some stakeholders proposed recommendations for EN standards in this sector and they expressed theirwillingness to start working as soon as possible. Some have sent a letter of support for the standardisationproject and some other have produced a first draft of a new proposal for an EN.

Considering the importance of the involvement and concrete recommendations of stakeholders, and giventhe high priority of the ageing European population and the quality of services that are to be provided tothem, AFNOR recommends that three levels of action can be separately or simultaneously considered.

First action: Network Animation (recommendation to both European Community and CEN):AFNOR recommends to EU and to CEN to support the creation of a multi-stakeholders forum.

Second action: Support of European Standardisation work (recommendation to EuropeanCommunity): The feasibility study offered the opportunity to underscore a real need of having adebate on the older people issue at European level as well as a strong will to initiate someactions. AFNOR would recommend creating a Technical Committee dedicated to this issue.Third action: Promotion of European standardisation for Social Services (recommendation toCEN): Afnor recommends to CEN to promote European standardisation for Social Services in

order to coordinate the conclusions of the present feasibility study (M371/P5) and the ones onhome services (M371/P4). (Recommendation to CEN)

AFNOR insists on the fact that if any implementation of those recommendations would occur, they haveto be coordinated with DG employment on Open Method of Coordination.

Moreover some coordination is also needed with:

The recommendations from the feasibility study on Home Services (M371-Project 4), led byAFNOR as those services, as far as they concern elderly care should be treated in the long-term care TC.

The conclusions of the feasibility study on smart houses services for Elderly and DisabledPeople (M371-Project 11) led by NEN.

The conclusion of the CHESSS feasibility study as the recommendations on complaints andredress system should be directly referred with.

The Austrian initiative of creating a project committee on Sheltered Housing. The recentcreation of this CEN Project Committee shows that there is a need for Europeanstandardisation in the field of long-term care.


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TABLE OF CONTENTS

Executive Summary

List of Tables

List of Figures

1. INTRODUCTION

1.1 Policy context

1.2 Objective and deliverable

1.3 Definition of the scope of the feasibility study

1.4 Rationale for choosing the service area proposed

2. METHODOLOGY AND IDENTIFICATION OF STAKEHOLDERS

2.1 Five-steps methodology

2.1.1 step 1 : Research of information and preliminary data collection

2.1.2 step 2 : Detailed investigation

2.1.3 Step 3 : Analysis and synthesis of the different positions

2.1.4 Step 4 : Debate with European stakeholders

2.1.5 Step 5 : Final report and communication of the feasibility study results

2.2 Identification of main Stakeholders

3. THE RESIDENTIAL HOMES FOR OLDER PEOPLE SERVICES SECTOR : STRUCTURE OF THEMARKET AND STAKEHOLDERS

3.1 General overview of the sector structure

3.1.1 Prevalence of Dependent People living in Residential Homes across Europe

3.1.2 Decentralisation of social services

3.2 Main Economic ans Social Issues of the sector

3.2.1 Availibility and accessibility : face the growing demand

3.2.2 Face the need to develop a high quality workforce

3.2.3 More complex needs of Older People in the Residential Homes

3.2.4 Enhance the quality of measurement

3.3 Regulatory aspects: Public policy context and existing standardisation documents

3.3.1 European Policy and Older People

3.3.2 National strategy concerning long-term care for older people: an overview of public policies

3.3.3 Existing standards and regulations in European countries


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LIST OF ANNEXES (see separate document)

ANNEX A: INTERIM REPORT

ANNEX A-A: TABLE 1: List of contacts in NSB

ANNEX A-B: TABLE 2 List of contacts and events attended during first stepANNEX A-C: TABLE 3:List of contacts for the detailed investigation questionnaire

ANNEXE A-D: Letter for a preliminary interview (English version)

ANNEXE A-E: Letter for a preliminary interview (French version)

ANNEXE A-F: Table 4 Existing standards and regulations in European countries

ANNEXE A-G: Preliminary enquiry questionnaire to NSB and presentation Email

ANNEXE A-H: Questionnaire to stakeholders and introduction letter (French version)

ANNEXE A-I: Questionnaire to stakeholders and introduction letter (English version)

ANNEX B: Seminar Report

ANNEX C: Draft Form A

ANNEX D: List of participants European Seminar

ANNEX E: Stakeholders Position Statements

ANNEX E- A: AGEANNEX E- B: ANEC

ANNEX E- C: Union Sociale pour Lhabitat

ANNEX E- D: SALAR


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List of Tables

Table 1: List of contacts for in depth interviewsTable 2: Changes in the older populations of the EU, 2004-50

List of Figures

Figure 1: Five steps methodologyFigure 2: Dependent population by category of care (by institutions, formal home care,

informal or no careFigure 3: Public and private spending on long-term care (percent of GDP, 2003)Figure 4: Position of stakeholders regarding European Standardisation in the field

of residential homes for Older peopleFigure 5: SWOT Analysis of TC long-term care services to older and dependent persons


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1. INTRODUCTION

This final report stems from a feasibility study contract on residential homes for older people withinthe framework of mandate M/371 addressed to CEN by the European Commission. The objectiveof this document is to report the main steps and tasks completed as well as the results of thefeasibility study, and to present the conclusions and recommendations stemming from the

feasibility study as well as to focus on the operational steps to implement recommendations andassociated next steps that can be taken afterwards.

Key issues of chapter 1

Objectives of the feasibility study on residential homes (EuropeanCommission addressed Programming Mandate M/371)

Identify technical data, existing guidelines or standards which could be used

as basis for this workInvestigate on stakeholders perceptions (positive or negative perceptions,main barriers and facilitators), interests and needs

Check whether the conditions of success for the European harmonisation aremet

Rationale

The number of persons being admitted to residential homes should increasevery quickly in Europe over the next years (approximately 43 % before 2010),leading to an increase in the number of establishments.

Development of different types of services, increasingly adapted to thetreatment of numerous pathologies.

A concern about information on the services delivered by establishments andability to compare them.

Different types of structures currently exist, proposing varied services, withvariable quality levels. This complicates the comparison between the servicesprovided by these establishments for older people and their families.

Developing a European standard on services provided by residential homes

for older people would allow:

To protect the rights of people all over Europe and to defend ethicalprinciples

To avoid potential abuses from service providers

To ensure transparency on the quality of the services supplied

To develop professionalism in this field of activity

To promote cross-border free circulation of persons in Europe


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1.1 Policy context

The European Commission recognizes that the European standardisation system, whereby allinterested parties transparently and openly develop standards on a consensus basis with whichcompliance is voluntary, could contribute to the single market in services. This contribution would takethe form of breaking down barriers to trade and thus fostering competitiveness.

Within this framework Programming Mandate M/371 in the field of services was given to CEN by theEuropean Commission to support projects aimed at looking in depth at a particular service area andanalysing it with the involvement of the stakeholders, in order to demonstrate the need for andpossibilities of use of standards. This study is one of the eleven projects proposed by CEN to theEuropean Commission on various services, each project being conducted by a NationalStandardisation Body (NSB). The outcome of each project will provide an input to the overall CENprogramme of standardisation work, where the project results show market and European relevance.

1.2 Objective and deliverable

The main purpose of this feasibility study is to check whether the conditions of success for theEuropean harmonisation of Residential Homes for older people services are met, i.e.:

Support and interest from a sufficient number of countries for this work (involvement ofrelevant stakeholders, financial support);

Availability of technical data, existing guidelines or standards, which could be used as a basisfor this work.

1.3 Definition of the scope of the feasibility study

The present study addresses Residential Homes for older people. The services concerned areBusiness-to-Consumer (B-to-C) services.

The services provided by residential homes for older people involve activities aimed at sheltering olderpeople and offering them facilities and services for a good quality of life. They generally includeservices of different nature, such as:

reception and registration of older people

living environment (public and private areas, quality of premises)

catering (quality of food, menus adapted to disabled people, time schedule)

social activities

coordination of care

1.4 Rationale for choosing the service area proposed

National public authorities have an important role in the organisation, provision and financing of theseservices. Because they are services of general interest , protection of citizen should be considered,and national public authorities have to be involved in the elaboration (if any) of European documents(either mandatory or voluntary).

The context: An increasing number of older and dependant people:

The population of older and dependant European people may increase of 72%3. Because there is a

prevalence/higher incidence of disease and incapacity/disability in older age groups, Addressingmultiple medical and social care needs becomes an issue for residential homes. The services offeredin residential homes for older persons ought to be accompanied by the development of different typesof services, increasingly adapted to the treatment of numerous pathologies.

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The admission of older people to a residential home is an important step in their life. For them andtheir families, choosing an establishment is not an easy task. Being informed about the servicesdelivered by establishments, comparing them and assessing the quality of services provided isessential in making a confident decision.

Different types of structures currently exist, proposing varied services, with variable quality levels. Thiscomplicates the comparison of the services provided by these establishments for the elderly personsand their families.

That is why clarifying the service commitments of these establishments, associated with a definition ofthe performance level of the services, would facilitate the creation of common references in Europe.

Main arguments in favour of harmonising the services supplied by residential homes for olderpeople

Although the ability of these institutions/service providers to provide users with integrated patterns ofcare depends largely on available resources and national legislation with regard to what is covered via

insurance and procurement mechanisms, there are some arguments that could be considered infavour of having a European standards for these services.

Developing a European standard on services provided by residential homes for older people couldallow:

1. to protect the rights of people all over Europe and to defend ethical principles: the ethicalframework is aimed at insisting on the principles related to the respect of the fundamental rights ofadmitted persons in complement of national legislation that can vary from one European countryto another. By giving recommendations for clear and transparent contractual arrangements, aEuropean standard can contribute to establishing a reliable relationship between the elderlypersons, their family and the professionals working in the establishments.

2. to avoid potential abuses from service providers (particularly regarding the most disabledand older people): Identifying and clarifying the nature of services provided by residential homesfor older people would help to answer user expectations be very useful and respond to the lack oftransparency.

3. to ensure transparency on the quality of the services supplied : Defining the contents ofthe services supplied and their performance level, codes of good practices, the ethical framework,etc., in a transparent way would contribute to protect user interests.

4. to contribute to upgrade the professionalisation process of the organisation providingthe services in this field of activity: To develop a European standard on the services related toResidential homes for older people may accompany the upgrading the professionalisationprocess. It may help to put forward the importance of the staff skills and competence on the level

of quality of the service provided. A European standard on these services can therefore be acomplement of the national regulations existing in the countries, enhancing.

5. to promote cross-border free circulation of persons in Europe: when older people live incross-border areas, and when they have the financial and systemic ability to do so, they maychoose establishments in a nearby foreign country for reasons of proximity or cheaper costs. Thischoice is for the moment quite conditionned by the modalities of insurance policies covering or notextra-territorial or if the older person lives in a system providing publicly funded social care(insurance-based or tax funded NHS systems). This practice induces the free circulation ofpersons. Considered that, at European level, there is a will to promote the free circulation ofpersons, one could this tendency may develop over the next years. A European standard wouldthen help older people and their families to compare the levels of services supplied by differentestablishments. It would also contribute in facilitating the access to the cross-border market and

would reinforce the free circulation of people all over Europe.


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2. METHODOLOGY AND IDENTIFICATION OF STAKEHOLDERS

Key issues of chapter 2

To realise this feasibility study AFNOR proposed to conduct the projectin five steps:

- Step 1: Information research and data collection- Step 2: Detailed investigation- Step 3: Analysis and synthesis of the different positions- Step 4: Debate with European stakeholders- Step 5: Final report and communication of the feasibility study

results

The main European Stakeholders of the sector have participated in theinvestigation of this feasibility Study.

This consultation either by questionnaire, interviews, attendance to thesectors key meetings, has allowed to grasp information on context,market, main issues and needs of the stakeholders as well as theirposition concerning European Standardisation of the Residential Homesfor Older People Services.

The European Seminar organised in CEN premises has been a keyopportunity to discuss the previous results and to go further as somerecommendations on European Standardisation for the ResidentialHomes for Older People Services were made.


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To realise this feasibility study AFNOR proposed to conduct the project in five steps:

Step 1: Information research and data collection

Step 2: Detailed investigation

Step 3: Analysis and synthesis of the different positions

Step 4: Debate with European stakeholders

Step 5: Final report and communication of the feasibility study results

Figure 1 is an illustration of this 5 steps methodology.

Figure 1: Five steps methodology

11

METHODOLOGY

Starting of

EC mandate

2007 2008

Detailed

investigation Interim reportDebate with

EuropeanStakeholders

Final report andresults and

communication

Analysis andsynthesis of the

different

positions

Information

research andpreliminary

data collection

2.1 Five-steps methodology

2.1.1 Step 1: Research of information and preliminary data collectionThe purpose of this step was, in the limits of this study, to collect information from CEN membercountries about: the local markets of services to resident persons, existing practices, existingregulations, standardisation background, the strategies of the service providers.

All European NSB have been contacted by e-mail to collaborate in giving national information: oncethe contact person was identified in each NSB, a questionnaire was sent in order to get some contactdetails about the national partners and to collect information about existing standards, regulations andchallenges in the field of residential homes for older people. Moreover the objective of this step was toget the position of national stakeholders (through NSB) regarding European standardisation. Theeight NSB which have answered the questionnaire are BSI (United Kingdom), DIN (Germany), LST(Lithuania), MSA (Malta), NEN (The Netherlands), SN (Norway), SNV (Switzerland) and UNI (Italy)

4

4For the complete list of NSB, see the interim report annexes


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In greater details, here are the NSB perceptions on a European standard:

- In Germany, European standardization related to residential homes for elderly people isconsidered as an interesting subject: Such a standard would contribute to increasing cross-border settlement of retired persons. DIN emphasizes that ,for the moment, stakeholders arealready involved in the implementation of DIN 77800;

- In Switzerland, there is an interest for this subject but participation in European standardizationwork will depend on the market needs;

- In Italy, a European standard is perceived as helpful as it would assist in guaranteeing a goodlevel of services for the elderly. In Italy, each region has a specific law that defines structuraland safety requirements;

- In Norway, many services in this area are regulated by national regulations. However,participation would be considered depending on the scope of standardization work. Theywould be interested in working on quality of services; quality of content, contracts; terminology;

- In the Netherlands, this is an important topic and it is considered very helpful to learn fromother countries and share practices. They would be interested in participating in EuropeanStandardization work;

- In Malta, the NSB contact explains that standards can help to improve the level of servicebeing offered. Standardization can protect users as regards service quality. European work isperceived as useful to service providers as they could make use of the best common practicesdocumented in the standards;

- For the UK, such European standardisation work would allow equalization of care5

Data on the context, main issues and needs of standardisation in the field of residential homes forolder people have also been obtained by using Internet and document research and by attendingcongresses or meetings related to residential homes for older people. This step has also allowed toidentify more stakeholders especially at the European level. As an anticipation of step 2, somenational or European associations of service providers/users have been contacted (phone, email or

mail) in order to proceed to some in depth-interviews (by phone or face-to-face).

Step one was a very important step since it gave the opportunity to inform all standardisation partnersabout the European Community Mandate M371. It also allowed to get preliminary information onstakeholders and their positions on European Standardisation.

The conclusion of this step is that there was a real interest of the above-cited countries to participate insome European Standardisation work if any. However, some more discussions on the scope wereseen as necessary in order to really take into account the national particularities of each country (forinstance, in some countries, this field of activity is nationally regulated, which is not in itself an obstaclebut would need further discussions)

6.

2.1.2 Step 2: Detailed investigation

The purpose of this step was to go further in gathering of information on the needs and expectations ofstakeholders, in getting accurate information on the market of residential homes for older people, andfinally in exploring the opportunities for the development of standardisation projects in this area.

A detailed questionnaire has been e-mailed to some previously identified stakeholders 1) to the 30CEN members (European Committee for Standardisation) 2) to key stakeholders (service providers,national and European professional associations, users' associations, NGOs, etc..) working in thissector

7.

5This comment seems to refer to a will to coordinate the quality of services in the residential homes for older people sector.

6See Interim Report in Annex

7See Interim Report in Annex


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Some in-depth interviews with stakeholders have been organised. The table below presents thecontact persons and their organisation which have participated to in-depth interviews during thefeasibility study.

Table 1: List of contacts for in depth interviews

Organization contacted (for preliminaryinterview or questionnaire)

Name of contact Country

AGE Anne-Sophie Parent and Isabelle BORGES Europe

ANEC Nina Klemola Europe

FIAPA Fdration Internationale des Associationsde Personnes Ages

Andr Zawadski Europe

GERIAPA Groupement d'tudes, de recherches etd'initiatives pour l'aide aux personnes ges

Jean Detolle (Former President) France

International association of gerontology andgeriatrics Secretariat Office Pr Dr Bayens Belgium

International association of gerontology andgeriatrics Secretariat Office: European work groupon nursing Homes

Dr Marcus Leser Switzerland

PRO-CERT D. Kalbfuss Switzerland

To go further, in order to complete the previously described steps, some information has beengathered by directly participating to some meetings (i.e. participation in the social Platform Seminar,

AGE administration council, Eurocarers meeting, Comit dorientation stratgique Sant of AFNOR)and with some document research

8.

Step 2 has allowed getting a precise picture of the issues of the sector with different sources ofinformation and different methods. It can be noted that the views and the concerns of stakeholdersgrasped through questionnaires and interviews were generally coherent with some issues identified inEuropean reports and studies on this question

9.

2.1.3 Step 3: Analysis and synthesis of the different positions

The aim of this step was to propose a draft document presenting the various positions of thestakeholders on the standardisation proposal in the field of residential homes for older people, and asynthesis.

The results of the previously-described steps have been analysed in order to display clear informationon the task achieved and to present the first results of the study as well as the first orientationsconcerning Stakeholders positions on European Standardisation. This work has been compiled in thefeasibility interim report and sent to European Community.

The results highlighted that there were a lot of discrepancies across European countries in theavailability and quality of the services and that there is a lack of human resources that was impactingon the quality of the service; that some more user-oriented competences were needed ; and that therewas a need to clarify the users/providers relation (more transparency and more power for the user forinstance).

8PROCARE, for instance, has an objective of providing an overview of national contexts, current debates and outcomes of

reforms and model projects in healthcare (http://www.euro.centre.org/procare/) and EUROFAMCARE (http://www.uke.uni-hamburg.de/extern/eurofamcare/beschreibung.php).

9For instance EUROFAMCARE report or (http://www.uke.uni-hamburg.de/extern/eurofamcare/beschreibung.php) or European

Commission and AARP joint conference on long-term care september 2006).
http://www.euro.centre.org/procare/http://www.uke.uni-hamburg.de/extern/eurofamcare/beschreibung.phphttp://www.uke.uni-hamburg.de/extern/eurofamcare/beschreibung.phphttp://www.uke.uni-hamburg.de/extern/eurofamcare/beschreibung.phphttp://www.uke.uni-hamburg.de/extern/eurofamcare/beschreibung.phphttp://www.euro.centre.org/procare/


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This step 3 has been a very important step as it was the first available report on the ongoing study. Itgave the opportunity to have a basis for further discussions with stakeholders and as such contributedto the success of step 4.

2.1.4 Step 4: Debate with European stakeholders

The aim of this step was to organise a debate between the stakeholders (NSBs and other partners) inorder to assess if developing a European Standard in the field of residential homes for older peoplewas a relevant means to contribute to the performance of the services in this sector.

The stakeholders10

identified or contacted during the previous steps, including European Commissionand CEN representatives, have been invited to participate to this European seminar. The interimreport of step 3, with the analysis/synthesis of the issues, needs and stakeholders positions, has beenthe main basis of the discussion.

The seminar has been an opportunity to put forward the degree of agreement concerning therelevance of European Standardisation for the residential homes for older people sector. It has alsoallowed to collect the suggestions and recommendations of stakeholders concerning the way to meetthese needs. Most of those recommendations were concrete proposals for some European

standardisation work, while some other were rather promoting European directives in the field ofservices or not supporting the idea of European standardisation at all.

This step 4 was a decisive one, as the stakeholders were meeting altogether and could discuss theirconcerns about their field of activity. The seminar has been a fruitful opportunity to, on the one hand,grasp the real motivation of the stakeholders and on the other hand to have a better understanding ofthe possible reluctance concerning the implementation of some European Standardisation Work. Afterthe seminar the conclusions and recommendations have been presented in a seminar report, whichhas been sent to all seminar participants, including CEN and EC representatives

11.

2.1.5 Step 5: Final report and communication of the feasibility study results

The deliverable of Step 5 is the current document. The objective of this document is to report themain steps and tasks completed during the feasibility study, to present the conclusions andrecommendations stemming from the feasibility study and finally, to focus on the operational stepsto implement recommendations and associated next steps that can be taken afterwards.

2.2 Identification of the main Stakeholders12

The following participants are among the main stakeholders working at European level and they arerepresentatives of numerous national associations related to older people or to services providers.

European Association for Directors of Residential Care Homes for the Elderly (E.D.E)

E.D.E. (European Association for Directors of Residential Care Homes for the Elderly) is a

professional federation of directors/managers of Residential and Nursing Homes from all over Europe.

Members in E.D.E. are organisations of home directors coming from 18 European countries andaltogether there are 23 national associations. The European Countries represented are the following:

Austria, Belgium, Czech Republic, Denmark, Estonia, Finland, France, Germany, Hungary, Latvia,Italy, Lithuania, Luxembourg, Netherlands, Poland, Serbia, Slovenia, Sweden, Switzerland.

10List of Participants for European Seminar (see Appendix)

11See Seminar report on Residential Homes for Older People services in Annex.

12Information about Stakeholders has been extracted from their website
http://www.ede-eu.org/En/?id=5C18BCFEhttp://www.ede-eu.org/En/?id=4F6D617Ehttp://www.ede-eu.org/En/?id=68083CFEhttp://www.ede-eu.org/En/?id=2596AA7Fhttp://www.ede-eu.org/En/?id=6498E1FFhttp://www.ede-eu.org/En/?id=5F843B7Ehttp://www.ede-eu.org/En/?id=6FAEAEFEhttp://www.ede-eu.org/En/?id=0416D47Fhttp://www.ede-eu.org/En/?id=3CA663FFhttp://www.ede-eu.org/En/?id=376F05FFhttp://www.ede-eu.org/En/?id=4FD4357Ehttp://www.ede-eu.org/En/?id=68D6617Ehttp://www.ede-eu.org/En/?id=68D6617Ehttp://www.ede-eu.org/En/?id=4FD4357Ehttp://www.ede-eu.org/En/?id=376F05FFhttp://www.ede-eu.org/En/?id=3CA663FFhttp://www.ede-eu.org/En/?id=0416D47Fhttp://www.ede-eu.org/En/?id=6FAEAEFEhttp://www.ede-eu.org/En/?id=5F843B7Ehttp://www.ede-eu.org/En/?id=6498E1FFhttp://www.ede-eu.org/En/?id=2596AA7Fhttp://www.ede-eu.org/En/?id=68083CFEhttp://www.ede-eu.org/En/?id=4F6D617Ehttp://www.ede-eu.org/En/?id=5C18BCFE


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La Plate-forme Europenne des Personnes ges (AGE)

AGE, the European Older Peoples Platform, aims at expressing and promoting the interests of the

older people in the European Union. AGE is involved in political activities and informative concerning

the elderly issues. AGE fights against all forms of discrimination related to ageing.

Source: AGE website: http://www.age-platform.org

International association of Gerontology and Geriatrics (IAGG)

The European region of the International Association of Gerontology is the organisation that groups all

the countries of the geographic European Continent. It is the European part of the World Organisation:

the International Association of Gerontology (IAG) was founded in 1952.

European members are Albania, Austria, Belgium, Bulgaria, Czech Republic, Denmark, Estonia,

Finland, France, Georgia, Germany, Greece, Hungary, Ireland, Israel, Italy, Luxembourg, Malta,

Netherlands (The), Norway, Poland, Portugal, Romania, Russia, Serbia, Slovak Republic, Slovenia,

Spain, Sweden, Switzerland, Turkey, Ukraine, United Kingdom.

Fdration Internationale des Associations de Personnes Ages(FIAPA)La FIAPA, Fdration Internationale des Associations de Personnes Ages (International Federationof Older People Association) was created in Paris in 1980 by representatives of four countries(Belgium, Spain, France and Italy) and is now present in about 60 countries on the 5 continents with300 millions members.

Social PlatformPlatform of European Social NGOs (Social Platform) is the alliance of representative Europeanfederations and networks of non-governmental organisations active in the social sector.


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3. The Residential Homes for Older People services sector: Structure of themarket and stakeholders

Key Issue of Chapter 3: Structure of the Residential Homes

for Older People market and Stakeholders

Characteristics of the market

Residential homes for older people are found within what is termed theinstitutional setting which includes several types of residences as nursingHomes, old age homes, sheltered housing or offering respite care, hospitalstay, rehabilitation services, hospice-palliative care, dementia care amongstothers.

They are part of the long-term care sector and have historically been fundedby the public sector.

In order to reduce observed fiscal deficits, some Member Statesgovernments have introduced competitive elements in either the provision ordelivery of services. The providers are sometimes functioning within aprivate environment but the sector is regulated and depends on whether theMember States have introduced a fully-fledged purchaser provider split.

Residential Settings for Older People tend in some cases to be intertwinedand integrated with home care provision allowing in that sense the transitionand follow-up from one setting into the other.

In most European countries, residential homes for Older People arebecoming less prevalent than home care.

The general trend concerning users preferences for a place to live, is tochoose home care or family care over institutional care. However some studyshow that there are national differences in this choice, Norwegians clearlyprefer residential settings when they cannot anymore care for themselves

High rate of older dependent persons live in residential homes in Belgiumand Malta

Main economic and social issues of the Residential Homes for Older People

services sector

Concerns related to the growing demand: make sure there are enoughresources to purchase and to deliver those services, including theavailability of a qualified workforce

Make sure those services can meet the complex needs of Older People in theResidential Homes

Reinforce transparent contractual relationships across many differentservices providers (mainly across the public sector and its correspondingagencies and the diversity of services providers)


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Residential homes for Older People are institutional settings, including several types of residences asNursing Homes

13and other types of residential services for older people. For instance, in the

comparative work from Eurofamcare project14

residential care is defined as the traditional housing forolder people including nursing homes and old age homes. Some other living arrangements areconsidered according to the type of services delivered like Respite, Sheltered Housing, Hospital stay,Rehabilitation, Hospice-palliative care, Dementia. They are part of the long-term care services sector:

"The term long-term care services refers to the organisation and delivery of a broad range of servicesand assistance to people who are limited in their ability to function independently on a daily basis overan extended period of time. There are two complementary components of this definition: the carecontinues over a long time period, and second the care is usually provided as an integratedprogramme across service components. The services may be provided in a variety of settingsincluding institutional, residential or home care."

15

This long-term care dimension also explicitly highlights the fact that Residential Settings for OlderPeople are only one side of the coin of this sector of services, which tend to be more and moreintertwined and integrated with home care

16. Therefore, the development of the latter influences the

evolution of the first.

As these services have a general interest dimension, the Member States have a responsibilityregarding the level of quality of these services. As such they have to get involved in the definition ofEuropean minimum requirement.

The market of Residential Homes, under the public sectors umbrella, has been for a few years theobject of major transformations with many quality/efficiency challenges due to demographic factorsand cost pressures. Most Member States had to take important decisions concerning this sectorservices, especially funding, monitoring and assessment. Some changes are taking place, with thehelp of incentives offered by national public policies to facilitate home care and with the introduction ofcompetitive elements in long-term care provision.

3.1 General overview of the sector structure

Except in a few countries, the residential homes are no more the most prevalent form of services forolder people. Some shifts have occurred in some countries concerning the reduction of residentialhomes in their traditional forms towards some more adapted settings and home care.

3.1.1 Prevalence of Dependent People living in Residential Homes acrossEurope

Comparing the prevalence of residential homes across Europe shows the disparities between membercountries. The table below illustrates the proportion of dependent people using institutional settingsacross Europe by comparison with some other types of care (formal home care or informal or no care).The following table is referring to Institutional care which are not of course restricted to residential

homes for older people but, however, allows to show the general tendency towards home care.

13"Long-term nursing care comprises a range of services required by persons with a reduced degree of functional capacity,

either physical or cognitive, who are consequently dependent on help for basic activities of daily living (ADL). This physical ormental disability can be the consequence of chronic illness, frailty in old age, mental retardation or other limitations of mentalfunctioning and/or cognitive capacity. In addition, help concerning monitoring status of patients in order to avoid furtherworsening of ADL status."Source: OECD. Health Division. 2008. Conceptual Framework and definition of long-term care expenditurehttp://www.oecd.org/dataoecd/24/58/40760216.pdf14

Elizabeth Mestheneos and Judy Triantafillou on behalf of the EUROFAMCARE group. Supp orting Family Carers of OlderPeople in Europethe Pan-European Background, p.4815

OECD. Health Division. 2008. Conceptual Framework and definition of long-term care expenditurehttp://www.oecd.org/dataoecd/24/58/40760216.pdf16

See Final report on Feasibility study on Home services which is also part of the Programming Mandate M/371 in the field ofservices given to CEN by the European Commission to support projects aimed at looking in depth at a particular service areaand analysing it with the involvement of the stakeholders, in order to demonstrate the need for and possibilities of use ofstandards.
http://www.oecd.org/dataoecd/24/58/40760216.pdfhttp://www.oecd.org/dataoecd/24/58/40760216.pdfhttp://www.oecd.org/dataoecd/24/58/40760216.pdfhttp://www.oecd.org/dataoecd/24/58/40760216.pdfhttp://www.oecd.org/dataoecd/24/58/40760216.pdfhttp://www.oecd.org/dataoecd/24/58/40760216.pdf


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Figure 2: Dependent population by category of care (by institutions, formal home care, informalor no care

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

BE DK DE ES IE IT LU FI

SE UK CZ LT LV MT PL SK S

I

Average

informal or no care

Formal home care

In institution

Source: Figure 2, Dependent population by category of care (by institutions, formal home care, informal or no care) from AARPreport

17, p. 7)

In some European countries, home care has become the most used type of long-term care services,except for Belgium, Malta, Finland, Czech Republic, Lithuania, Latvia, Poland and Slovenia whereinstitutional settings are remaining the most used long-term care services among dependent people.For instance, in Malta (48%) and in Belgium (35%) of the dependent population are located ininstitutions while in Denmark, Spain, Italy, Lithuania, Latvia, and Poland, only around 10% of thedependent population can be found in institutions. The use of institutional or domiciliary settingsdepends firstly on the availability of the different settings and the degree of dependency and need ofhelp of the dependent

17The Cross-Atlantic exchange to advance long-term care. Background Paper prepared for European Commission and AARP.

Joint Conference on Long-Term Care. 13 September 2006. Brussels, Belgium


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Although there is a shift from residential settings towards homecare, there are still national differencesin the way older people choose where they wish to live, and more specifically when people projectthemselves in the future, when they cannot care anymore for themselves:

"There are significant cultural differences in the preferences of older people themselves for this type of care(residential settings), though the time at which they were asked about their preferences as well as thewider socio-economic conditions in which they find themselves, also influences their responses. The criticalissue is what they prefer when they can no longer care for themselves: nine out of ten Norwegian olderpeople preferred a residential setting, while the Swiss also preferred professional care. Similar tendenciescan be found in the Czech Republic, Poland, Slovenia and Hungary, where older people in need for careare put on waiting lists for admission and expanding long-term care and residential facilities".

18

3.1.2 Tendency to decentralisation and outsourcing of social services

More and more, there has been a technical decentralisation of social care giving more importance toagencies, municipalities, and other local public authorities which are, with the non-profit sector, theproviders for residential homes for older people services.

By giving more authority to municipalities, Member States encouraged the latter to find alternativesolution , by reinforcing the substantial shift from centralised to decentralised welfare and encouraging

the shift to private services providers., introducing competition and private services providers.

In U.K, for instance, outsourcing has been encouraged by the Community Care reform in 1992. As aresult, the number of elderly homes between 1984 and 1994 has increased by approximately 10% forprivately run facilities (5,5% for public facilities).

In Germany, the sector mainly led by welfare public funded organisations like the Red Cross forinstance, has been challenged by the introduction of competitive conditions between welfareorganizations and private companies since the introduction of long-term care (LTC) insurance in 1995.

Even in Sweden, known for the importance of the public sector for the provision of long-term careprivate market has been introduced

19.

Figure 3: Public and private spending on long-term care (percent of GDP, 2003)

0

0,5

1

1,5

2

2,5

3

3,5

AU CA DE IE JA NL NZ NO PL ES SE UK US

Private exp. On inst. Care

Private exp. On home care

Public exp. On inst. care

Public exp. On home care

Source: Figure 5, from The Cross-Atlantic exchange to advance long-term care. Background Paper prepared for EuropeanCommission and AARP. Joint Conference on Long-Term Care. 13 September 2006. Brussels, Belgium, p. 15

18

Elizabeth Mestheneos and Judy Triantafillou on behalf of the EUROFAMCARE group. Supporting Family Carers of OlderPeople in Europethe Pan-European Background, p.4919

Go, Kazuhisa. Industrial Research Dept. The Introduction of Market Mechanisms for long-term care Services - AnInternational Comparison with Implications for Japan. http://www.nli-research.co.jp/english/socioeconomics/1998/li9804.html


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3.2 Main Economic and Social Issues of the sector

Residential Homes for Older People Sector is facing some important challenges. This sector has to beable to face the impact of demographic changes on the demand for services, by ensuring that theservices could be purchased and would be available. They also have to fit to the specific needs of theoldest of the old people. Addressing multiple medical and social care needs becomes an issue for

residential homes since older old persons tend to exhibit a prevalence of chronic and multipleconditions).

3.2.1 Availability and accessibility: face the growing demand

Considering the ageing of the European population (countries with the oldest population are all inEurope), the question of the availability of the adapted services to older people as well as the questionof access to care can be asked.

() the ageing of Europes population is expected to have a major impact on demand for social careservices, and it is predicted that nearly every household will eventually be using social care services ofsome kind. At the same time, the ageing of the working population will gradually lead to a contraction of theworkforce. By 2030, the population of working age could be reduced to millions in the EU25 compared withthe present 303 million. This has implications for the growth potential and sustainability of not onlypensions and benefits, but even more so for that of social services for the elderly

20.

Table 2: Changes in the older populations of the EU, 2004-50

Age 65+ Age 80+

2004 2050 % change 2004 2050 % change

Population in millions

EU25 75.3 133.3 77.0 18.2 49.9 174

EU15 65.2 114.2 75.2 16.3 44.2 172

EU10 10.1 19.1 89.1 1.9 5.7 193

Percent of total population

EU25 16.5 29.4 4.0 11.0

EU15 17.0 29.4 4.3 11.4

EU10 13.6 29.2 2.6 8.7

Source: EU data from the Directorate-General for Economic and Financial Affairs, European Commission,adapted from Table 5. Changes in the older populations of the EU and the US, 2004-50

21

This is a major concern because the availability of social care services (including long-term careservices) is a serious issue for Europe:

In most EU15 Member States, demand for social care services exceeds the supply of resources available,particularly in terms of the labour supply. In some of the (New Member States) and acceding countries,labour supply may exceed demand, but only in the short term. In the longer term, a pattern similar to that inthe old Member States will emerge

22.

20European Foundation for the Improvement of Living and Working Conditions. Employment in social care in Europe, 2006

p.221

The Cross-Atlantic exchange to advance long-term care. Background Paper prepared for European Commission and AARP.Joint Conference on Long-Term Care. 13 September 2006. Brussels, Belgium22

European Foundation for the Improvement of Living and Working Conditions. Employment in social care in Europe, 2006p.2


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3.2.2 Face the need to contribute to upgrade the professionalisation process ofthe organisation providing the services

There is a high pressure on the labour force in the context of residential homes for older people sector.With some important challenges to reinforce the social care, including residential homes for olderpeople such as

23

Better working conditions for staff More training and skills and a need for more user-oriented approach

Enhanced public image to make the residential homes for Older People moreattractive

Upgrade the organisation of structure for delivering quality services

3.2.3 More complex needs of Older People in the Residential Homes

As a result of the trend toward home care, the residential homes need are becoming more and morethe alternative for home care when the person need heavy care services:

The general trend is thus that, where available, home or community care is preferred to institutional care.This is not to say that institutional care provision should be dismantled, particularly as regards patients withsevere disability/illness."

24

The average age of entrance in older people establishments is increasing (people are generally over84 years old), the admitted persons very often suffer from incapacities (relative to hygiene, feeding,communication, alteration of senses, difficulty in moving around) and from different pathologies.Moreover the shift from residential care to home care has impacted the type of population found in theresidential settings as they have more complex problems with severe disabilities/illnesses.

Overall, as many countries indicated there is an increase in both the age and leve l of dependency of olderpeople, as well as the proportion of dementia sufferers, in all types of residential care ()

25.

In general, it is noted that "most care giving at home is also provided to the oldest old, but on theaverage, the people receiving formal care at home are younger than institutionalized people

26". The

sector of residential homes is then facing this challenge of offering adapted services to the olderpeople with severe disabilities for whom home care is no longer the most appropriate alternative

27.

3.2.4 Enhance the quality of services measurement

Decentralisation of the Welfare State and outsourcing put forward the question of the measurement ofthe quality of the services Some European studies underscore that:

Withdrawal of direct service provision by the state has raised some concerns about the quality of care.

How to achieve a desired standard of care across many different service providers, who are increasinglymanaged by independent agencies rather than local authorities, is one of the most pertinent questions atpresent in the care sector

28.

The coordination with the private market for the services delivered to older people need to bemonitored by public sector which is still holding the responsibility for those services. Across European

23European Foundation for the Improvement of Living and Working Conditions. Employment in social care in Europe, 2006

24European Commission, Directorate-General for Employment, Social Affairs and Equal Opportunities, Unit E2. Joint Report on

Social Protection and Social Inclusion. 2007, p.10625

Elizabeth Mestheneos and Judy Triantafillou on behalf of the EUROFAMCARE group. Supporting Family Carers of OlderPeople in Europethe Pan-European Background, p.4026

The Cross-Atlantic exchange to advance long-term care. Background Paper prepared for European Commission and AARP.

Joint Conference on Long-Term Care. 13 September 2006. Brussels, Belgium, p.727European Foundation for the Improvement of Living and Working Conditions. Employment in social care in Europe, 200628

Employment in social care in Europe, Summary p.9 European Foundation for the Improvement of Living and WorkingConditions, 2006 website: www.eurofound.eu.int


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countries29

there are discrepancies between the availability of some quality control for those services.Quality control is one important focus point of some recent health and social services reforms that willinclude some requirements on accreditation of service providers.

3.3 Regulatory aspects: Public policy context and existing standardisation

documents

3.3.1 European Policy and Older People

After the adoption of the Strategy of Lisbon in March 2000, social priorities of the EuropeanCommunity were more focused on the Older People.

Even if European Community doesnt have any global competence on those long-term care servicesageing, the Open Method of Coordination, allows the EC to act in this domain by promoting a strongcooperation between member states on employment, social welfare (pensions), fight against thepoverty, social exclusion, education and recently in the field of the long-term care.

The process: the Open Method of Coordination

In broad areas of economic, employment and social policy the Member States have to meet reformchallenges that are similar throughout Europe. The convergence of challenges has been driven by theeconomic integration within the internal market, and the effects of the fast changing global economy,technological innovation and demographic change. Therefore, a new instrument was needed whichsupports the Member States in their reform efforts, while respecting their legal competences.

Set up at the Lisbon European Council of March 2000, the Open Method of Coordination provides thisframework of political coordination without legal constraints. Member States agree to identify and promotetheir most effective policies in the fields of Social Protection and Social Inclusion with the aim of learningfrom each others experiences.

This is a flexible and decentralised method, which involves:

Agreeing to common objectives which set out high-level, shared goals to underpin the entire process;

Agreeing to a set of common indicators which show how progress towards these goals can bemeasured;

Preparing national strategic reports, in which Member States set out how they will plan policies overan agreed period to meet the common objectives;

Evaluating these strategies jointly with the European Commission and the Member States.

Source : http://ec.europa.eu/employment_social/spsi/the_process_en.htm

3.3.2 National strategy concerning long-term care for older people: an overviewof Public policies

The table below lists the current legislation and public policies related to long-term care in Europeancountries. Some of those recent legislation and public policy are about reorganisation of health andsocial sector (Denmark) including the reinforcement of quality of services. Some are about reinforcingthe home care trend, to make home care more accessible (24 hour care at home policy in Austria;

29 Elizabeth Mestheneos and Judy Triantafillou on behalf of the EUROFAMCARE group. Supporting Family Carers of Older

People in Europe the Pan-European Background and European Commission, Directorate-General for Employment, SocialAffairs and Equal Opportunities, Unit E2. Joint Report on Social Protection and Social Inclusion. 2007.


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Free choice of home help in Denmark ; The Borloo Plan in France) or aim at supporting family care fordying person (Family hospice Sabbatical in Austria).

Table 3: Recent Legislation and law projects concerning long-term careAustria October 2007 Making 24h care at home more accessible

Austria November 2004 Austrian Health Reform 2005: Agreement reached

Austria: November 2003 Family Hospice Sabbatical

Austria: November 2003 Long-Term Care Policy

Denmark: April 2008 The Chronic Care Model - A new approach in DK

Denmark: 31/03/2005 Public sector reform - a bill has been proposed

Denmark: 09/10/2004 Public sector reform and hospital management I

Denmark: October 2003 Free choice of home help

Estonia: April 2007 Changes in Hospital Reform process in Estonia

Finland: October 2007

November 2005

Vouchers in social and health care - follow up

France 2005 Solidarity Fund for financing dependency

France 2003 Nursing plan

France 2005 Borloo Plan

Germany November 2003 Intergenerational equalization of burdens

Netherlands October 2006 Law on Social Support

Netherlands October 2006 Law on Social Support

Netherlands November 2004 The Social Support Act (WMO)

Netherlands April 2004 Client Linked Budgets

Netherlands: 03/12/2003 Modernization of national health insurance scheme

Netherlands October 2003 Integrated Care for Elderly

Poland April 2008 Ideas of drug reimbursement system changes III

Poland October 2007 Guidelines for waiting lists

Poland October 2007 Ideas of drug reimbursement system changes II

Poland April 2007 Converting acute hospital beds into long-term beds

Poland November 2006 Program on cancer disease prevention

Slovenia April 2008 Resolution-the national health care plan 2008-2013

Slovenia April 2007 Act on insurance for long-term care

Spain October 2007 Long-term care System Implementation in Spain

Spain April 2006 Integrated care for the elderly

Spain October 2003 Integrating health and social care

Spain October 2003 Ageing society, health and dependence

Switzerland April 10, 2005 New system for financing of nursing care

United Kingdom April 2008 The Health and Social Care Bill

United Kingdom April 2006 Integrating community health and social care

United Kingdom April 2006 Health care reform in England: progress and plans

United Kingdom September 2005 Developments in social care

United Kingdom October 2003 Long-term care for older people

Source: Compilation of results from the Health Policy Monitor http://www.hpm.org/index.jsp


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3.3.3 Existing standards and regulations in European countries

In addition to national regulations, the member states have developed standards in the field of long-term care.

Guides for the use of EN ISO 9001 (quality management systems) and 9004 (guide in health services

for performance improvement) are found in Denmark, Finland, Luxembourg and Ireland (9001).

In Italy, there are nursing home guidelines defining some service requirements for the implementationof the UNI EN ISO Standards: At UNI, there is an active working group on these questions at themoment.

In Spain, there are three new projects of national standards concerning long-term care:- PR PNE 158101 - SPAIN - Services for the promotion of the personal autonomy. Management of theresidential homes- PNE 158301 - SPAIN - Services for the promotion of the personal autonomy. Management of thehome help service- PNE 158401 - SPAIN - Services for the promotion of the personal autonomy. Management of thetelecare service

The United Kingdom has developed BIP 072:2005 Quality of care in residential homes for the elderly.

In Germany, the DIN standard (DIN 77800) defines quality requirements for providers of assisted livingfor the elderly. It targets elderly persons owning flats in private residences where many assistanceservices are offered. For instance: medical care, cleaning services, security guard, entrance control.This new type of residence is a growing business and is not government regulated.

In France, the French standard NF X 50-058: Residential homes for older people. The ethicalframework and service commitments concern services offered by residential homes for dependent andindependent older people. It also deals with services offered to temporary residents of the homes: dayprogrammes, temporary stay, etc.This document defines the ethical framework and general principlesof the services. It specifies service commitments related to reception, preliminary information,

admission, environment and lifestyle, provision of care, catering service, social life, temporaryaccommodations, and departure from the home. It describes the skills that are linked to servicequality. This standard deals with services offered by all residential homes for older people within thehome itself. The services concerned also include those offered to people who do not residepermanently at the home, such as temporary accommodations, and so on.

In France, still, stakeholders also pointed out EVA as a referential (self-assessment) document. EVA isused for accreditation and evaluation by governmental agencies.

More focused on Home services, the NF X50-056 "Services aux personnes domicile" (services forresident persons) has recently been revised and published (may 2008). This standard has beenrevised in order to fit with the new legislation of the services for resident persons (home services),including the Borloo Plan, 2005).

In the Netherlands, some regulations (guidelines) have been developed to ensure the quality of healthcare in homes for older people, (long-term care) nursing homes and for (professional) homecare.

Norway has also developed some regulations concerning all services for the elderly. Moreover, someprivate organizations have developed guidelines on quality of services and contracts.

In Switzerland, public health services and private organisations have developed private standards.

In Slovenia, while implementing the e-qalin project, SIST has also drafted an ASIS standard onproviders of services and an ASIS standard for providing medical care services in homes for theelderly.


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At European level, E.D.E is currently leading a European project on quality: "E-qalin": EuropeanQuality-improving innovative learning in residential care homes for the elderly-. This project proposestraining for residential care home directors (seewww.e-qalin.net)

30.

Recently, CEN Member Countries have accepted the new project proposal from Austria on Qualityrequirements for services and service providers of sheltered housing for the elderly . The proposed

scope for this work item is the following: This standard is applicable to providers of sheltered housingfor the elderly. This standard is applicable irrespective of the legal form of ownership of the propertyand the usage relationships established therewith. Work on this European standard should be startingin the next months.

To conclude, most health and social care services standards concern are management guidelines andvery few (Germany, Italy, Spain, and France) deal with service requirements based on users'expectations and the quality of services. The German standard however targets different customers(private residences with assisted living) and Italy is working more specifically on nursing homes.France proposes a more generic document on service requirements. All standards concerningresidential homes services are elaborated at national level until now, the only European initiative thatwill include all member countries being the Austrian

31initiative on sheltered housing. This initiative

may show an existing need for a European answer to some problems traditionally answered at

national level.

Chapter 3 has shown that the residential homes for older people is a sector under pressureconsidering the demographic issue, the associated cost and the probability that there could be somelack of resources to face all the future needs. In order to answer those challenges, many of theEuropean countries have engaged some health care and social services reforms allowing moreoutsourcing of services related to elderly. Still at national level, some standards have been drafted insome countries, either focusing on management (including the satisfaction of clients) either focusingon the general principles of the service.

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The Austrian Province of the Camillians is the main contractor of the pilot project E-Qalin31 This is an Austrian initiative that has received a positive vote from CEN member countries (through their nationalstandardisation institutes). This initiative concerns all EU Member States as the European standard, one published will bepart of the national standard collection.
http://www.e-qalin.net/http://www.e-qalin.net/http://www.e-qalin.net/http://www.e-qalin.net/


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4. IDENTIFIED NEEDS AND RECOMMENDATIONS FROM STAKEHOLDERS

Key Issue of Chapter 4: Identified Needs and Recommendationsfrom Stakeholders

The needs expressed by the stakeholders are reflecting the main issuesand challenges of the residential homes for older people sector.

One of the main issues is related to the concern of stakeholders on theavailability and the competence of human resources.

Some new competences, like user-oriented competences should beenhanced.

European relevance has been underscored by the stakeholders.

Residential homes for Older people may be confronted with challengesthat are common to European Countries (Countries with the higher ratesof older people are all in Europe!)

Most of them see that a common langage is needed as well as a share ofgood practices

Some Cross-Border services need to be approached in a European globalperspective, as some people can move from one country to another whenchoosing Residential Homes for Older People.

Differences between countries have of course to be taken into accountand they should be considered in any standardisation work.

Most stakeholders find relevant European standardisation in order to meetthose needs and they have proposed some recommendations concerningsome subject that could be the object of future European standardisationwork in the field of Residential Homes for Older People.

Stakeholders have made recommendations for some possible Europeanstandardisation work. They concern terminology and classification,Process of the services, description of the characteristics of the services,Training and competence and a diversity of Guidelines.

Finally on the basis of the conclusions of the study and the stakeholdersrecommendations, this report recommends to European Commission andto European Committee for Standardisation (CEN), three actions and thenext steps that can be taken in order to implement them.


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4.1 Needs

Stakeholders have underscored a diversity of needs concerning the general issue of quality of care orthe more specific issue of needs related to standardisation and tools.

Prevention of the lack of human resources (including motivation of staff; valorisation of

informal care)This sector of activity seems to be characterized by certain difficulties in hiring human resources,mainly because of the negative image of the job.

Working with older people is seen as a low prestige and tiring job. This negative image of jobs in olderpeople homes is a real issue as it is impacting the motivation of people to work in this field. Nowadays,some stakeholders underscore how difficult it is to hire the required staff. To some extent, this leads tohiring under-qualified workers who are more available and cheaper.

The representative of the European Association underscores this problem of staff hiring, and morespecifically of competent staff. This problem seems to be particularly acute for nurses.

In all the countries of Europe there is nurses' scarcity. And in some there is a scarcity of helps nursing. To

face this problem, several countries recruit nursing staff who does not master enough the language of thecountry. Involving the nurse in France: even if the financing is guaranteed, there is a true problem ofrecruitment. The reasons are multiple but essentially attractiveness of the geriatrics and the weak

payment for the sector old people's home.

Considering the negative perception of those jobs, one of the basic challenges would be to make jobsin the sector of home services more attractive.

This situation is impacting the quality of care delivered to elderly persons: as employees areoverwhelmed by their jobs, they have less time to work on the autonomy of the cared person.

User-oriented competence is requested

Some providers and users are underscoring the importance of services being more user-oriented. Forinstance, In France32

, they have developed tools to enhance bientraitance (well -treatment). This kindof tools may be a complement to legal framework concerned with maltreatment and abuse is deterredwith possibilities of redress. The "bientraitance" is defined as a set of concepts and attitudes, whichtake into account the phases of development of the person with the objective of allowing him/her aharmonious development. It is a multi-field reflection registered in the project of establishment (see theMOBIQUAL programme).

Some new competences should be enhanced: for instance some residential home directors orassociations underscore training needs. Those needs are beyond technical aspects; they concern therelation between users and carers, especially with frail persons. They wish to have staff with morerelational competence profiles than assistance profiles in their establishments. This goes withconsideration for the empowerment of the elderly as a priority.

To clarify the contractual relationship between the users and service providersSome stakeholders pointed out that it was necessary to improve the service transparency and allcontractual aspects in this sector. Services would gain from being better adapted to clients' needs andexpectations, and from better information. This can be done through the clarification of procedures andthe provision of clear information to the users and to their family.

Needs concerning tools33

Stakeholders pointed out some needs concerning tools such as the need to have a minimum standard for quality across Europe while some other would wish to have some common qualityinstruments that are adapted to the culture of the member states. The need for some standardisation

32In France, in addition to the 2002-2 legislation (law on social services), the agency for evaluation (ANESM) has published

recommendations: Bientraitance: Dfinition et repres pour la mise en oeuvre (Aot 2008)33

Those needs are more detailed in the 4.3 section


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documents describing the processes and assessment tools including admission processes, have alsobeen pointed out. Another specific need is about a tool to enhance the social life in residential andnursing homes. Finally, guidelines for a minimum set of skills for social workers considering the newcompetences needed within the residential homes could be useful.

European relevance: Needs related to quality standards at European Level

Caring for older people in a Europe confronted with the demographic changes, is in fact coming face toface with important social and economic challenges that we can only master together.We need the same standards of quality throughout Europe to make the foundation for our professionalaction and so avoid a social "second-rate" attitude. Finding good solutions to each older person's housingand living conditions, as well as more humane working conditions for the staff in our homes is a vision thatwe together in E.D.E. work for!

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The management of long-term care services is now a European issue. European countries have theoldest population of the world and all countries in Europe can try to coordinate to face this issue aswell as the related quality of services issue. Indeed, the EU is supportive of high quality of carethrough, as explained earlier, the Open Method of Coordination, which encourages Member States toprovide healthcare and long-term care services of high quality.

The EU open method of coordination applied in the field of long-term care has high quality of care as oneof its three main objectives. It is important that this objective should be supported at all levels ofadministration, from EU to municipal level. The EU could support national strategies for high-quality socialcare through better utilising its policy measure of open coordination. Governments could set qualityassurance standards and monitor their implementation and delivery. Public administration at local level andproviders of effective social care could be better acquainted with quality issues through the support ofnational and EU policy administration.35

For some stakeholders, the long-term care issue can be addressed at European level as well. Most ofthem have acknowledged the importance of sharing good practices and have a European strategy foraddressing their needs.

More over, it is thus perceived as positive that countries share their good practices and help each

other attain a high quality of care.

However, European standardisation work would have to take into account some elements that couldmake standardisation more difficult:

Different life styles and economic levels in the European countries: very different materialconditions and cultural backgrounds.

The specificities of every region (rural / city) or cultural background (languages, family models,management of home care, etc.) could give a European standard only an indicative role andwithout interest for certification or use

Federalism (Switzerland)36

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project 5 - residential homes

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