Feasibility and opportunity to develop a standardisation work programme concerning residential homes for older people

Food Industry and Health Care Department

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

Final Report
Submitted by AFNOR Association Franaise de Normalisation

July 2008

Sara LA TOUR AFNOR Tl: +33 (0)1 41 62 82 94 Fax: +33 (0)1 49 17 90 00 sara.latour@afnor.org AFNOR Association Franaise de Normalisation 11 rue Francis de Pressens 93571 LA PLAINE SAINT DENIS CEDEX Tel:33 (0) 1 41 62 82 47 Fax:33 (0) 1 49 17 90 00

Executive Summary This final report stems from a feasibility study contract on residential homes for older people within the framework of mandate M/371 addressed to CEN by the European Commission. The objective was to explore 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 results have highlighted that residential homes for the older people services are challenged by demographic changes (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 was perceived as a relevant means to meet those challenges either by users and by providers and some recommendations were proposed by stakeholders. Chapter one is reminding the policy context and the rationale for this feasibility study on residential homes 1 for older people. The population of older and dependant European people may increase of 72% .

Because there is a prevalence/higher incidence of disease and incapacity/disability in older age groups, 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 the development of different types of services, increasingly adapted to the treatment of numerous pathologies.
The admission of older people to a residential home is an important step in their life. For them and their family, choosing an establishment is not an easy task. Being informed about the services delivered by establishments, comparing them and assessing the quality of services provided is essential in making a confident decision. Different types of structures currently exist, proposing varied services, with variable quality levels. This complicates the comparison of the services provided by these establishments for the elderly persons and their families. That is why clarifying the service commitments of these establishments, associated with a definition of the performance 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 be considered 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, to avoid potential abuses from service providers and to ensure transparency on the quality of the services supplied, to develop professionalism in this field of activity, and finally, to promote cross-border circulation of persons in Europe. Chapter 2 describes the methodology and the tasks completed at each step. Data has been collected through NSB, questionnaires and in depth-interviews. Finally, a seminar has been organised and main stakeholders had the opportunity to debate on the relevance of European standardisation in the field of residential homes for older people and then to propose recommendations for European standardisation work. During the step 1, research of information and preliminary data collection has been completed. The purpose of this step was to collect information from each country about: the local markets of services to resident persons, existing practices, existing regulations, standardisation background, the strategies of the service providers. The conclusion of this step is that there was a real interest of the participating countries to participate in some European Standardisation work if any. However, some more discussions on the scope were seen as necessary in order to really take into account the national particularities of each country (for instance, in some countries, this field of activity is nationally regulated, which is not in itself an obstacle but would need further discussions). During Step 2, the detailed investigation, The purpose of this step was to go further in gathering of information on the needs and expectations of stakeholders, in getting accurate information on the sector of residential homes for older people, and finally in exploring the opportunities for the development of standardisation projects in this area. Step 2 has allowed getting a precise picture of the issues of the sector
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Comment les personnes dpendantes seront-elles entoures en 2030? Projections europennes . Population et socits. Avril 2008

with different sources of information and different methods. It can be noted that the views and the concerns of stakeholders grasped through questionnaires and interviews were always coherent with the results of European and national reports and studies. The aim of step 3 was to propose a draft document presenting the various positions of the stakeholders on the standardisation proposal in the field of residential homes for older people, and a synthesis. The results highlighted that there were a lot of discrepancies across European countries in the availability and quality of the 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 the users/providers relation (more transparency and more power for the user for instance). The aim of step 4 was to organise a debate between the stakeholders (NSBs and other partners) in order to assess if developing a European Standard in the field of residential homes for older people was a relevant means to contribute to the performance of the services in this sector. The seminar has been an opportunity to put forward the degree of agreement concerning the relevance of European Standardisation for the residential homes for older people sector. It has also allowed to collect the suggestions and recommendations of stakeholders concerning the way to meet these needs. Most of those recommendations were concrete proposals for some European standardisation work, while some other were rather promoting European directives in the field of services or not supporting the idea of European standardisation at all. Step 5 is the elaboration of current document. The objective of this document is to report the main steps and tasks completed during the feasibility study, to present the conclusions and recommendations stemming from the feasibility study and finally, to focus on the operational steps to implement recommendations 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 main economic and social issues of the sector as well as the policy and regulatory context. This sector is under pressure considering the demographic issue, the associated cost and the probability that there could be some 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 have historically been funded by public sector. The issue of reducing fiscal deficits has brought some member states 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 integrated with 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 care or family care, even if there are national differences in this choice, like for Norwegians, for instance, who clearly 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 to face the growing demand and make sure there are enough resources to purchase and to deliver those services, including the availability of a qualified workforce. Moreover, this sector has to prepare itself to meet the more complex needs of older people in the residential homes. Finally, as the public sector is decentralising and outsourcing more and more services in this sector, another important issue is to reinforce 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 the European 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 strong cooperation 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 an overview 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 the commission to the European parliament, the council, the European economic and social committee and the committee of the regions. A renewed commitment to social Europe. Reinforcing the Open Method of coordination for Social Protection and Social Inclusion

trend, to make home care more accessible (24 hour care at home policy in Austria; Free choice of home help in Denmark; The Borloo Plan in France) or aim at supporting family care for dying person (Family hospice Sabbatical in Austria). A review of the national standards in this sector of activity shows that most health and social care services standards concerns are addressed via management guidelines and very 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 concerning residential homes services are elaborated at national level until now, the only European initiative that will include all member countries being the Austrian initiative on sheltered housing services (April 2008). This initiative shows an existing need for a European answer to some problems traditionally answered at national level. Chapter 4 focuses on the needs and recommendations concerning European standardisation. The first section describes the stakeholders needs while the second one illustrates their position towards European Standardisation. A third section reports all the concrete recommendations for European standardisation matters 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 really interested in clarifying the contract relation and confer more transparency to the relation between providers and users and need of some tools (guidelines on geriatric assessment, on information to be provided to users, on code of ethics and conduct) that Europeans standardisation would be able to help to build. 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 good practices and have a European strategy for addressing their needs. Among the main reasons why European standardisation should be conducted in the field of residential homes for older people, they have pointed out the mobility of workers and the cross-border services in the residential homes for older persons sector. More over, it is perceived as positive that countries share their best 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 make harmonisation more difficult (different life styles and economic levels in the European countries: very different material conditions and cultural backgrounds; the specificities of every region (rural / city) or cultural background (languages, family models, management of home care, etc.). Recommendations put forward by stakeholders for the Residential Homes for Older People services sector 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 competence

Standardisation documents about means implementation of a good quality service)

(guidelines

documents

to

support

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

The feasibility study has been a fantastic opportunity to gather a lot of information and to put together different stakeholders from several European countries. A common aim was motivating them: the importance 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 their willingness to start working as soon as possible. Some have sent a letter of support for the standardisation project 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 given the high priority of the ageing European population and the quality of services that are to be provided to them, 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 European Community): The feasibility study offered the opportunity to underscore a real need of having a debate on the older people issue at European level as well as a strong will to initiate some actions. AFNOR would recommend creating a Technical Committee dedicated to this issue. Third action: Promotion of European standardisation for Social Services (recommendation to CEN): 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 on home services (M371/P4). (Recommendation to CEN)

AFNOR insists on the fact that if any implementation of those recommendations would occur, they have to 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 by AFNOR as those services, as far as they concern elderly care should be treated in the longterm care TC. The conclusions of the feasibility study on smart houses services for Elderly and Disabled People (M371-Project 11) led by NEN. The conclusion of the CHESSS feasibility study as the recommendations on complaints and redress system should be directly referred with. The Austrian initiative of creating a project committee on Sheltered Housing. The recent creation of this CEN Project Committee shows that there is a need for European standardisation in the field of long-term care.

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 THE MARKET 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

4. IDENTIFIED NEEDS AND RECOMMENDATIONS FROM STAKEHOLDERS

4.1 Needs and European relevance Needs related to quality standards at European level 4.2 Stakeholders positions on European Standardisation 4.3 Recommendations from Stakeholders 4.3.1 Terminology and classification 4.3.2 Process 4.3.3 Characteristics of the service 4.3.4 Training and competence 4.3.5 Standardisation documents about means

5. CONCLUSIONS AND RECOMMENDATIONS

5.1 CONCLUSIONS

5.2 RECOMMENDATIONS

5.2.1 ACTION 1 : Multi-stakeholders Forum : Recommendation to CEN and to EU 5.2.2 ACTION 2 : Recommendation to EU : Technical Committee on long-term care for older people with all recommended subjects 5.2.3 ACTION 3 : Recommendation to CEN : Communication on the innovative role of service standardisation related to social services

5.3 NEXT STEPS

5.3.1 Possible action plan to implement action 1 : Multi-Stakeholders Forum 5.3.2 Possible action plan to implement action 2 : A CEN Technical Committee on long-term care 5.3.3 Possible action plan to implement action 3 : Communication on the role of Standardisation on long-term care services

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 step ANNEX 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: AGE ANNEX E- B: ANEC ANNEX E- C: Union Sociale pour Lhabitat ANNEX E- D: SALAR

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

List of Figures
Figure 1: Five steps methodology Figure 2: Dependent population by category of care (by institutions, formal home care, informal or no care Figure 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 people Figure 5: SWOT Analysis of TC long-term care services to older and dependent persons

1. INTRODUCTION
This final report stems from a feasibility study contract on residential homes for older people within the framework of mandate M/371 addressed to CEN by the European Commission. The objective of this document is to report the main steps and tasks completed as well as the results of the feasibility 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 and associated next steps that can be taken afterwards.

Key issues of chapter 1

Objectives of the feasibility study on residential homes (European Commission addressed Programming Mandate M/371) Identify technical data, existing guidelines or standards which could be used as basis for this work Investigate on stakeholders perceptions (positive or negative perceptions, main barriers and facilitators), interests and needs Check whether the conditions of success for the European harmonisation are met Rationale The number of persons being admitted to residential homes should increase very 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 the treatment of numerous pathologies. A concern about information on the services delivered by establishments and ability to compare them. Different types of structures currently exist, proposing varied services, with variable quality levels. This complicates the comparison between the services provided 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 ethical principles 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

1.1 Policy context

The European Commission recognizes that the European standardisation system, whereby all interested parties transparently and openly develop standards on a consensus basis with which compliance is voluntary, could contribute to the single market in services. This contribution would take the 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 the European Commission to support projects aimed at looking in depth at a particular service area and analysing it with the involvement of the stakeholders, in order to demonstrate the need for and possibilities of use of standards. This study is one of the eleven projects proposed by CEN to the European Commission on various services, each project being conducted by a National Standardisation Body (NSB). The outcome of each project will provide an input to the overall CEN programme 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 the European 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 of relevant stakeholders, financial support); Availability of technical data, existing guidelines or standards, which could be used as a basis for this work.

1.3 Definition of the scope of the feasibility study

The present study addresses Residential Homes for older people. The services concerned are Business-to-Consumer (B-to-C) services. The services provided by residential homes for older people involve activities aimed at sheltering older people and offering them facilities and services for a good quality of life. They generally include services 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 these services. Because they are services of general interest , prot ection 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: 3 The population of older and dependant European people may increase of 72% . Because there is a prevalence/higher incidence of disease and incapacity/disability in older age groups, 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 the development of different types of services, increasingly adapted to the treatment of numerous pathologies.
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Comment les personnes dpendantes seront-elles entoures en 2030? Projections europennes . Population et socits. Avril 2008

The admission of older people to a residential home is an important step in their life. For them and their families, choosing an establishment is not an easy task. Being informed about the services delivered by establishments, comparing them and assessing the quality of services provided is essential in making a confident decision. Different types of structures currently exist, proposing varied services, with variable quality levels. This complicates the comparison of the services provided by these establishments for the elderly persons and their families. That is why clarifying the service commitments of these establishments, associated with a definition of the 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 older people Although the ability of these institutions/service providers to provide users with integrated patterns of care 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 in favour of having a European standards for these services. Developing a European standard on services provided by residential homes for older people could allow: 1. to protect the rights of people all over Europe and to defend ethical principles: the ethical framework is aimed at insisting on the principles related to the respect of the fundamental rights of admitted persons in complement of national legislation that can vary from one European country to another. By giving recommendations for clear and transparent contractual arrangements, a European standard can contribute to establishing a reliable relationship between the elderly persons, their family and the professionals working in the establishments. 2. to avoid potential abuses from service providers (particularly regarding the most disabled and older people): Identifying and clarifying the nature of services provided by residential homes for older people would help to answer user expectations be very useful and respond to the lack of transparency. 3. to ensure transparency on the quality of the services supplied : Defining the contents of the 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 providing the services in this field of activity: To develop a European standard on the services related to Residential homes for older people may accompany the upgrading the professionalisation process. 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 a complement of the national regulations existing in the countries, enhancing. 5. to promote cross-border free circulation of persons in Europe: when older people live in cross-border areas, and when they have the financial and systemic ability to do so, they may choose establishments in a nearby foreign country for reasons of proximity or cheaper costs. This choice is for the moment quite conditionned by the modalities of insurance policies covering or not extra-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 of persons. Considered that, at European level, there is a will to promote the free circulation of persons, one could this tendency may develop over the next years. A European standard would then help older people and their families to compare the levels of services supplied by different establishments. It would also contribute in facilitating the access to the cross-border market and would reinforce the free circulation of people all over Europe.

2. METHODOLOGY AND IDENTIFICATION OF STAKEHOLDERS Key issues of chapter 2 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

The main European Stakeholders of the sector have participated in the investigation of this feasibility Study. This consultation either by questionnaire, interviews, attendance to the sectors key meetings, has allowed to grasp information on context, market, main issues and needs of the stakeholders as well as their position concerning European Standardisation of the Residential Homes for Older People Services. The European Seminar organised in CEN premises has been a key opportunity to discuss the previous results and to go further as some recommendations on European Standardisation for the Residential Homes for Older People Services were made.

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

METHODOLOGY

Information research and preliminary data collection Starting of EC mandate

Detailed investigation

Analysis and synthesis of the different positions

Interim report

Debate with European Stakeholders

Final report and results and communication

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2.1 Five-steps methodology 2.1.1 Step 1: Research of information and preliminary data collection
The purpose of this step was, in the limits of this study, to collect information from CEN member countries about: the local markets of services to resident persons, existing practices, existing regulations, standardisation background, the strategies of the service providers. All European NSB have been contacted by e-mail to collaborate in giving national information: once the contact person was identified in each NSB, a questionnaire was sent in order to get some contact details about the national partners and to collect information about existing standards, regulations and challenges in the field of residential homes for older people. Moreover the objective of this step was to get the position of national stakeholders (through NSB) regarding European standardisation. The eight NSB which have answered the questionnaire are BSI (United Kingdom), DIN (Germany), LST 4 (Lithuania), MSA (Malta), NEN (The Netherlands), SN (Norway), SNV (Switzerland) and UNI (Italy)

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

In greater details, here are the NSB perceptions on a European standard: - In Germany, European standardization related to residential homes for elderly people is considered as an interesting subject: Such a standard would contribute to increasing crossborder settlement of retired persons. DIN emphasizes that ,for the moment, stakeholders are already involved in the implementation of DIN 77800; - In Switzerland, there is an interest for this subject but participation in European standardization work will depend on the market needs; - In Italy, a European standard is perceived as helpful as it would assist in guaranteeing a good level of services for the elderly. In Italy, each region has a specific law that defines structural and 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. They would 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 from other countries and share practices. They would be interested in participating in European Standardization work; - In Malta, the NSB contact explains that standards can help to improve the level of service being offered. Standardization can protect users as regards service quality. European work is perceived as useful to service providers as they could make use of the best common practices documented in the standards; - For the UK, such European standardisation work would allow equalization of care
5

Data on the context, main issues and needs of standardisation in the field of residential homes for older people have also been obtained by using Internet and document research and by attending congresses or meetings related to residential homes for older people. This step has also allowed to identify more stakeholders especially at the European level. As an anticipation of step 2, some national 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 partners about the European Community Mandate M371. It also allowed to get preliminary information on stakeholders 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 in some European Standardisation work if any. However, some more discussions on the scope were seen as necessary in order to really take into account the national particularities of each country (for instance, in some countries, this field of activity is nationally regulated, which is not in itself an obstacle 6 but would need further discussions) .

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 of stakeholders, in getting accurate information on the market of residential homes for older people, and finally 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 30 CEN members (European Committee for Standardisation) 2) to key stakeholders (service providers, national and European professional associations, users' associations, NGOs, etc..) working in this 7 sector .

This comment seems to refer to a will to coordinate the quality of services in the residential homes for older people sector. See Interim Report in Annex 7 See Interim Report in Annex
6

Some in-depth interviews with stakeholders have been organised. The table below presents the contact persons and their organisation which have participated to in-depth interviews during the feasibility study. Table 1: List of contacts for in depth interviews
Organization contacted (for preliminary interview or questionnaire) AGE Name of contact Anne-Sophie Parent and Isabelle BORGES Country Europe

ANEC

Nina Klemola

Europe

FIAPA Fdration Internationale des Associations de Personnes Ages GERIAPA Groupement d'tudes, de recherches et d'initiatives pour l'aide aux personnes ges International association of gerontology and geriatrics Secretariat Office International association of gerontology and geriatrics Secretariat Office: European work group on nursing Homes PRO-CERT

Andr Zawadski

Europe

Jean Detolle (Former President)

France

Pr Dr Bayens Dr Marcus Leser

Belgium Switzerland

D. Kalbfuss

Switzerland

To go further, in order to complete the previously described steps, some information has been gathered 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) 8 and with some document research . Step 2 has allowed getting a precise picture of the issues of the sector with different sources of information and different methods. It can be noted that the views and the concerns of stakeholders grasped through questionnaires and interviews were generally coherent with some issues identified in 9 European reports and studies on this question .

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 the stakeholders on the standardisation proposal in the field of residential homes for older people, and a synthesis. The results of the previously-described steps have been analysed in order to display clear information on the task achieved and to present the first results of the study as well as the first orientations concerning Stakeholders positions on European Standardisation. This work has been compiled in the feasibility interim report and sent to European Community. The results highlighted that there were a lot of discrepancies across European countries in the availability and quality of the 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 the users/providers relation (more transparency and more power for the user for instance).

PROCARE, 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.unihamburg.de/extern/eurofamcare/beschreibung.php). 9 For 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).

This step 3 has been a very important step as it was the first available report on the ongoing study. It gave the opportunity to have a basis for further discussions with stakeholders and as such contributed to 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) in order to assess if developing a European Standard in the field of residential homes for older people was a relevant means to contribute to the performance of the services in this sector. The stakeholders identified or contacted during the previous steps, including European Commission and CEN representatives, have been invited to participate to this European seminar. The interim report of step 3, with the analysis/synthesis of the issues, needs and stakeholders positions, has been the main basis of the discussion. The seminar has been an opportunity to put forward the degree of agreement concerning the relevance of European Standardisation for the residential homes for older people sector. It has also allowed to collect the suggestions and recommendations of stakeholders concerning the way to meet these needs. Most of those recommendations were concrete proposals for some European standardisation work, while some other were rather promoting European directives in the field of services 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 their concerns 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 of the possible reluctance concerning the implementation of some European Standardisation Work. After the seminar the conclusions and recommendations have been presented in a seminar report, which 11 has been sent to all seminar participants, including CEN and EC representatives .
10

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 the main steps and tasks completed during the feasibility study, to present the conclusions and recommendations stemming from the feasibility study and finally, to focus on the operational steps to 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 are representatives 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 and altogether 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.

10 11

List of Participants for European Seminar (see Appendix) See Seminar report on Residential Homes for Older People services in Annex. 12 Information about Stakeholders has been extracted from their website

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 Federation of 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 with 300 millions members.

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

3. The Residential Homes for Older People services sector: Structure of the market 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 the institutional setting which includes several types of residences as nursing Homes, old age homes, sheltered housing or offering respite care, hospital stay, rehabilitation services, hospice-palliative care, dementia care amongst others. They are part of the long-term care sector and have historically been funded by the public sector. In order to reduce observed fiscal deficits, some Member States governments have introduced competitive elements in either the provision or delivery of services. The providers are sometimes functioning within a private environment but the sector is regulated and depends on whether the Member States have introduced a fully-fledged purchaser provider split. Residential Settings for Older People tend in some cases to be intertwined and integrated with home care provision allowing in that sense the transition and follow-up from one setting into the other. In most European countries, residential homes for Older People are becoming less prevalent than home care. The general trend concerning users preferences for a place to live, is to choose home care or family care over institutional care. However some study show that there are national differences in this choice, Norwegians clearly prefer residential settings when they cannot anymore care for themselves High rate of older dependent persons live in residential homes in Belgium and 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 enough resources to purchase and to deliver those services, including the availability of a qualified workforce Make sure those services can meet the complex needs of Older People in the Residential Homes Reinforce transparent contractual relationships across many different services providers (mainly across the public sector and its corresponding agencies and the diversity of services providers)

Residential homes for Older People are institutional settings, including several types of residences as 13 Nursing Homes and other types of residential services for older people. For instance, in the 14 comparative work from Eurofamcare project residential care is defined as the traditional housing for older people including nursing homes and old age homes. Some other living arrangements are considered 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 services and assistance to people who are limited in their ability to function independently on a daily basis over an extended period of time. There are two complementary components of this definition: the care continues over a long time period, and second the care is usually provided as an integrated programme across service components. The services may be provided in a variety of settings 15 including institutional, residential or home care."

This long-term care dimension also explicitly highlights the fact that Residential Settings for Older People are only one side of the coin of this sector of services, which tend to be more and more 16 intertwined and integrated with home care . 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 responsibility regarding the level of quality of these services. As such they have to get involved in the definition of European minimum requirement. The market of Residential Homes, under the public sectors umbrella, has been for a few years the object of major transformations with many quality/efficiency challenges due to demographic factors and cost pressures. Most Member States had to take important decisions concerning this sector services, especially funding, monitoring and assessment. Some changes are taking place, with the help of incentives offered by national public policies to facilitate home care and with the introduction of competitive 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 for older people. Some shifts have occurred in some countries concerning the reduction of residential homes in their traditional forms towards some more adapted settings and home care.

3.1.1 Prevalence of Dependent People living in Residential Homes across Europe

Comparing the prevalence of residential homes across Europe shows the disparities between member countries. The table below illustrates the proportion of dependent people using institutional settings across 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.

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"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 or mental disability can be the consequence of chronic illness, frailty in old age, mental retardation or other limitations of mental functioning and/or cognitive capacity. In addition, help concerning monitoring status of patients in order to avoid further worsening of ADL status." Source: OECD. Health Division. 2008. Conceptual Framework and definition of long-term care expenditure http://www.oecd.org/dataoecd/24/58/40760216.pdf 14 Elizabeth Mestheneos and Judy Triantafillou on behalf of the EUROFAMCARE group. Supp orting Family Carers of Older People in Europe the Pan-European Background, p.48 15 OECD. Health Division. 2008. Conceptual Framework and definition of long-term care expenditure http://www.oecd.org/dataoecd/24/58/40760216.pdf 16 See Final report on Feasibility study on Home services which is also part of the Programming Mandate M/371 in the field of services given to CEN by the European Commission to support projects aimed at looking in depth at a particular service area and analysing it with the involvement of the stakeholders, in order to demonstrate the need for and possibilities of use of standards.

Figure 2: Dependent population by category of care (by institutions, formal home care, informal or no care
100%

90%

80%

70%

60% informal or no care 50% Formal home care In institution 40%

30%

20%

10%

0%

LU

DK

DE

UK

BE

ES

SE

PL

LT

M T

SK

CZ

LV

Source: Figure 2, Dependent population by category of care (by institutions, formal home care, informal or no care) from AARP report17, 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 where institutional 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 in institutions while in Denmark, Spain, Italy, Lithuania, Latvia, and Poland, only around 10% of the dependent population can be found in institutions. The use of institutional or domiciliary settings depends firstly on the availability of the different settings and the degree of dependency and need of help of the dependent

17

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

Av er a

ge

IE

FI

IT

SI

Although there is a shift from residential settings towards homecare, there are still national differences in the way older people choose where they wish to live, and more specifically when people project themselves 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 the wider socio-economic conditions in which they find themselves, also influences their responses. The critical issue is what they prefer when they can no longer care for themselves: nine out of ten Norwegian older people preferred a residential setting, while the Swiss also preferred professional care. Similar tendencies can be found in the Czech Republic, Poland, Slovenia and Hungary, where older people in need for care 18 are put on waiting lists for admission and expanding long-term care and residential facilities".

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 to agencies, municipalities, and other local public authorities which are, with the non-profit sector, the providers for residential homes for older people services. By giving more authority to municipalities, Member States encouraged the latter to find alternative solution , 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 a result, the number of elderly homes between 1984 and 1994 has increased by approximately 10% for privately run facilities (5,5% for public facilities). In Germany, the sector mainly led by welfare public funded organisations like the Red Cross for instance, has been challenged by the introduction of competitive conditions between welfare organizations 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 care 19 private market has been introduced . Figure 3: Public and private spending on long-term care (percent of GDP, 2003)
3,5 3 2,5 Private exp. On inst. Care 2 1,5 1 0,5 0 AU CA DE IE JA NL NZ NO PL ES SE UK US 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 European Commission 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 Older People in Europe the Pan-European Background, p.49 19 Go, Kazuhisa. Industrial Research Dept. The Introduction of Market Mechanisms for long -term care Services - An International Comparison with Implications for Japan. http://www.nli -research.co.jp/english/socioeconomics/1998/li9804.html

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 be able to face the impact of demographic changes on the demand for services, by ensuring that the services could be purchased and would be available. They also have to fit to the specific needs of the oldest 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 multiple conditions).

3.2.1 Availability and accessibility: face the growing demand

Considering the ageing of the European population (countries with the oldest population are all in Europe), the question of the availability of the adapted services to older people as well as the question of access to care can be asked.
() the ageing of Europes population is expected to have a major impact on demand for social care services, and it is predicted that nearly every household will eventually be using social care services of some kind. At the same time, the ageing of the working population will gradually lead to a contraction of the workforce. By 2030, the population of working age could be reduced to millions in the EU25 compared with the present 303 million. This has implications for the growth potential and sustainability of not only 20 pensions and benefits, but even more so for that of social services for the elderly .

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

Age 65+ 2004 2050 % change Age 80+ 2004 2050 % change

Population in millions EU25 EU15 EU10 75.3 65.2 10.1 133.3 114.2 19.1 77.0 75.2 89.1 18.2 16.3 1.9 49.9 44.2 5.7 174 172 193

Percent of total population EU25 EU15 EU10 16.5 17.0 13.6 29.4 29.4 29.2 4.0 4.3 2.6 11.0 11.4 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, 2004-5021

This is a major concern because the availability of social care services (including long-term care services) 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 in 22 the old Member States will emerge .

20

European Foundation for the Improvement of Living and Working Conditions. Employment in social care in Europe, 2006 p.2 21 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 22 European Foundation for the Improvement of Living and Working Conditions. Employment in social care in Europe, 2006 p.2

3.2.2 Face the need to contribute to upgrade the professionalisation process of the 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 older 23 people such as 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 more attractive 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 more the alternative for home care when the person need heavy care services:
The general trend is thus that, where available, home or communit y care is preferred to institutional care. This is not to say that institutional care provision should be dismantled, particularly as regards patients with 24 severe disability/illness."

The average age of entrance in older people establishments is increasing (people are generally over 84 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 the residential 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 older 25 people, as well as the proportion of dementia sufferers, in all types of residential care () .

In general, it is noted that "most care giving at home is also provided to the oldest old, but on the 26 average, the people receiving formal care at home are younger than institutionalized people ". The sector of residential homes is then facing this challenge of offering adapted services to the older 27 people with severe disabilities for whom home care is no longer the most appropriate alternative .

3.2.4 Enhance the quality of services measurement

Decentralisation of the Welfare State and outsourcing put forward the question of the measurement of the 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 increasingly managed by independent agencies rather than local authorities, is one of the most pertinent questions at 28 present in the care sector .

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

23 24

European Foundation for the Improvement of Living and Working Conditions. Employment in social care in Europe, 2006 European Commission, Directorate-General for Employment, Social Affairs and Equal Opportunities, Unit E2. Joint Report on Social Protection and Social Inclusion. 2007, p.106 25 Elizabeth Mestheneos and Judy Triantafillou on behalf of the EUROFAMCARE group. Supporting Family Carers of Older People in Europe the Pan-European Background, p.40 26 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.7 27 European Foundation for the Improvement of Living and Working Conditions. Employment in social care in Europe, 2006 28 Employment in social care in Europe, Summary p.9 European Foundation for the Improvement of Living and Working Conditions, 2006 website: www.eurofound.eu.int

countries 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 will include some requirements on accreditation of service providers.

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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 European Community were more focused on the Older People. Even if European Community doesnt have any global competence on those long-term care services ageing, the Open Method of Coordination, allows the EC to act in this domain by promoting a strong cooperation 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.

The process: the Open Method of Coordination

In broad areas of economic, employment and social policy the Member States have to meet reform challenges that are similar throughout Europe. The convergence of challenges has been driven by the economic 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 which supports 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 this framework of political coordination without legal constraints. Member States agree to identify and promote their most effective policies in the fields of Social Protection and Social Inclusion with the aim of learning from 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 be measured; Preparing national strategic reports, in which Member States set out how they will plan policies over an 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 overview of Public policies
The table below lists 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 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, Social Affairs and Equal Opportunities, Unit E2. Joint Report on Social Protection and Social Inclusion. 2007.

Free choice of home help in Denmark ; The Borloo Plan in France) or aim at supporting family care for dying person (Family hospice Sabbatical in Austria). Table 3: Recent Legislation and law projects concerning long-term care
Austria Austria Austria: Austria: Denmark: Denmark: Denmark: Denmark: Estonia: Finland: France France France Germany Netherlands Netherlands Netherlands Netherlands Netherlands: Netherlands Poland Poland Poland Poland Poland Slovenia Slovenia Spain Spain Spain Spain Switzerland United Kingdom United Kingdom United Kingdom United Kingdom United Kingdom October 2007 November 2004 November 2003 November 2003 April 2008 31/03/2005 09/10/2004 October 2003 April 2007 October 2007 November 2005 2005 2003 2005 November 2003 October 2006 October 2006 November 2004 April 2004 03/12/2003 October 2003 April 2008 October 2007 October 2007 April 2007 November 2006 April 2008 April 2007 October 2007 April 2006 October 2003 October 2003 April 10, 2005 April 2008 April 2006 April 2006 September 2005 October 2003 Solidarity Fund for financing dependency Nursing plan Borloo Plan Intergenerational equalization of burdens Law on Social Support Law on Social Support The Social Support Act (WMO) Client Linked Budgets Modernization of national health insurance scheme Integrated Care for Elderly Ideas of drug reimbursement system changes III Guidelines for waiting lists Ideas of drug reimbursement system changes II Converting acute hospital beds into long-term beds Program on cancer disease prevention Resolution-the national health care plan 2008-2013 Act on insurance for long-term care Long-term care System Implementation in Spain Integrated care for the elderly Integrating health and social care Ageing society, health and dependence New system for financing of nursing care The Health and Social Care Bill Integrating community health and social care Health care reform in England: progress and plans Developments in social care Long-term care for older people Making 24h care at home more accessible Austrian Health Reform 2005: Agreement reached Family Hospice Sabbatical Long-Term Care Policy The Chronic Care Model - A new approach in DK Public sector reform - a bill has been proposed Public sector reform and hospital management I Free choice of home help Changes in Hospital Reform process in Estonia Vouchers in social and health care - follow up

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

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 longterm 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 implementation of the UNI EN ISO Standards: At UNI, there is an active working group on these questions at the moment. 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 the residential homes - PNE 158301 - SPAIN - Services for the promotion of the personal autonomy. Management of the home help service - PNE 158401 - SPAIN - Services for the promotion of the personal autonomy. Management of the telecare 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 living for the elderly. It targets elderly persons owning flats in private residences where many assistance services 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 ethical framework and service commitments concern services offered by residential homes for dependent and independent older people. It also deals with services offered to temporary residents of the homes: day programmes, temporary stay, etc. This document defines the ethical framework and general principles of the services. It specifies service commitments related to reception, preliminary information, admission, environment and lifestyle, provision of care, catering service, social life, temporary accommodations, and departure from the home. It describes the skills that are linked to service quality. This standard deals with services offered by all residential homes for older people within the home itself. The services concerned also include those offered to people who do not reside permanently 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 is used for accreditation and evaluation by governmental agencies. More focused on Home services, the NF X50-056 "Services aux personnes domicile" (services for resident persons) has recently been revised and published (may 2008). This standard has been revised 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 health care 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, some private 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 on providers of services and an ASIS standard for providing medical care services in homes for the elderly.

At European level, E.D.E is currently leading a European project on quality: "E-qalin": European Quality-improving innovative learning in residential care homes for the elderly-. This project proposes 30 training for residential care home directors (see www.e-qalin.net) . Recently, CEN Member Countries have accepted the new project proposal from Austria on Quality requirements 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 housing for the elderly. This standard is applicable irrespective of the legal form of ownership of the property and the usage relationships established therewith. Work on this European standard should be starting in the next months. To conclude, most health and social care services standards concern are management guidelines and very 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 concerning residential homes services are elaborated at national level until now, the only European initiative that 31 will include all member countries being the Austrian initiative 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 pressure considering the demographic issue, the associated cost and the probability that there could be some lack of resources to face all the future needs. In order to answer those challenges, many of the European countries have engaged some health care and social services reforms allowing more outsourcing of services related to elderly. Still at national level, some standards have been drafted in some countries, either focusing on management (including the satisfaction of clients) either focusing on the general principles of the service.

30 31

The Austrian Province of the Camillians is the main contractor of the pilot project E-Qalin This is an Austrian initiative that has received a positive vote from CEN member countries (through their national standardisation institutes). This initiative concerns all EU Member States as the European standard, one published will be part of the national standard collection.

4. IDENTIFIED NEEDS AND RECOMMENDATIONS FROM STAKEHOLDERS Key Issue of Chapter 4: Identified Needs and Recommendations from Stakeholders The needs expressed by the stakeholders are reflecting the main issues and challenges of the residential homes for older people sector. One of the main issues is related to the concern of stakeholders on the availability and the competence of human resources. Some new competences, like user-oriented competences should be enhanced. European relevance has been underscored by the stakeholders. Residential homes for Older people may be confronted with challenges that are common to European Countries (Countries with the higher rates of older people are all in Europe!) Most of them see that a common langage is needed as well as a share of good practices Some Cross-Border services need to be approached in a European global perspective, as some people can move from one country to another when choosing Residential Homes for Older People. Differences between countries have of course to be taken into account and they should be considered in any standardisation work. Most stakeholders find relevant European standardisation in order to meet those needs and they have proposed some recommendations concerning some subject that could be the object of future European standardisation work in the field of Residential Homes for Older People. Stakeholders have made recommendations for some possible European standardisation 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 stakeholders recommendations, this report recommends to European Commission and to European Committee for Standardisation (CEN), three actions and the next steps that can be taken in order to implement them.

4.1 Needs
Stakeholders have underscored a diversity of needs concerning the general issue of quality of care or the 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 older people 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 to hiring under-qualified workers who are more available and cheaper. The representative of the European Association underscores this problem of staff hiring, and more specifically 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 the country. Involving the nurse in France: even if the financing is guaranteed, there is a true problem of recruitment. 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 jobs in the sector of home services more attractive. This situation is impacting the quality of care delivered to elderly persons: as employees are overwhelmed 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. For 32 instance, In France , they have developed tools to enhance bientraitance (well -treatment). This kind of tools may be a complement to legal framework concerned with maltreatment and abuse is deterred with possibilities of redress. The "bientraitance" is defined as a set of concepts and attitudes, which take into account the phases of development of the person with the objective of allowing him/her a harmonious development. It is a multi-field reflection registered in the project of establishment (see the MOBIQUAL programme). Some new competences should be enhanced: for instance some residential home directors or associations underscore training needs. Those needs are beyond technical aspects; they concern the relation between users and carers, especially with frail persons. They wish to have staff with more relational competence profiles than assistance profiles in their establishments. This goes with consideration for the empowerment of the elderly as a priority. To clarify the contractual relationship between the users and service providers Some stakeholders pointed out that it was necessary to improve the service transparency and all contractual aspects in this sector. Services would gain from being better adapted to clients' needs and expectations, and from better information. This can be done through the clarification of procedures and the provision of clear information to the users and to their family. Needs concerning tools
33

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 quality instruments that are adapted to the culture of the member states. The need for some standardisation
In 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
32

documents describing the processes and assessment tools including admission processes, have also been pointed out. Another specific need is about a tool to enhance the social life in residential and nursing homes. Finally, guidelines for a minimum set of skills for social workers considering the new competences 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 to face 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 professional action and so avoid a social "second-rate" attitude. Finding good solutions to each older person's housing and living conditions, as well as more humane working conditions for the staff in our homes is a vision that 34 we together in E.D.E. work for!

The management of long-term care services is now a European issue. European countries have the oldest population of the world and all countries in Europe can try to coordinate to face this issue as well as the related quality of services issue. Indeed, the EU is supportive of high quality of care through, as explained earlier, the Open Method of Coordination, which encourages Member States to provide 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 one of its three main objectives. It is important that this objective should be supported at all levels of administration, from EU to municipal level. The EU could support national strategies for high-quality social care through better utilising its policy measure of open coordination. Governments could set quality assurance standards and monitor their implementation and delivery. Public administration at local level and providers of effective social care could be better acquainted with quality issues through the support of national and EU policy administration.35

For some stakeholders, the long-term care issue can be addressed at European level as well. Most of them have acknowledged the importance of sharing good practices and have a European strategy for addressing 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 could make standardisation more difficult: Different life styles and economic levels in the European countries: very different material conditions 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 and without interest for certification or use 36 Federalism (Switzerland) .

4.2 Stakeholders positions on European Standardisation

As underscored previously, the feasibility study allowed to get the position of representatives of European associations and platforms as well as some national points of view on how European standardisation could contribute to upgrade the quality of the services offered in residential homes for Older people. Taking into account that Service provision is already guaranteed via national legislation, standardisation could contribute, through the share of good practices, to optimize the organisation of the services providers

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Prof. Dr. Wilfried Schlter, President EDE Source: Internet Site of the European Association for Directors of Residential Care Homes for the Elderly E.D.E. 35 Employment in social care in Europe, Summary p.9 European Foundation for the Improvement of Living and Working Conditions, 2006 website: www.eurofound.eu.int 36 Although federalism in Europe is not only a Swiss issue, this point has been raised by Swiss participants.

The conclusions of the feasibility study show that there are four types of perceptions considering European standardisation. Majority of stakeholders (BSI consumer representative, AGE representative, FIAPA, AROMDEMS, Fondation Mdric Alzheimer, Equalin project representatives, IAGG, Hacettepe University representative): In favour of European Standardisation documents and identified possible work items A part of stakeholders: Mixed support to European standardisation or interrogations on European Standardisation relevance (ANEC, Social Platform) c) Minority of stakeholders (SALAR) : No support of European Standardisation a) A majority of stakeholders are in favour of European Standardisation and identified possible work items Stakeholders directly dealing with European issues of protection of users and older people pointed out many reasons for having European standards to improve the quality of services at European level. Differences between countries have of course to be taken into account and they should be considered in any standardisation work. Most stakeholders have concrete needs regarding the improvement of residential homes for older people services; A majority of stakeholders perceive that European standardisation can contribute to improve the quality of Residential Homes for Older people Services; A majority of stakeholders identified some possible work items in order to increase the need of improvement of quality of Residential Homes for Older People Services. In this category, the stakeholders are supporting European standardisation, without any distinction between the types of documents (guidelines, standards, etc). b) Mixed support or interrogations on European Standardisation relevance A part of the stakeholders underlines the importance of European standardisation for this field of activity but at the same time described some situations in which European standardisation should be carefully considered. Some stakeholders are considering that European standardisation is an important tool but probably not in itself. The limits of European standardisation have to be well defined and standards, if any are to 37 be developed in a larger European legislative frame (ANEC, EDF) . The concern was about the voluntary aspect of standardisation. For some participants (ANEC, Caritas), quality of services in general and more specifically the safety aspect (ANEC) is a very central issue and cannot be let to voluntary application. It is thus recommended by ANEC that legislation should first define the quality of services framework in which standards can be developed. DG employment representatives were concerned about the delimitation of member states competence and European standardisation competence. Residential Homes for Older Persons are included in the large debate of social services of general interests involving public authority, services providers, users. This suggests that coordination between CEN and DG employment work on quality framework document is needed. As the services offered in residential homes for older people are services of general interest, they are regulated within member states. For DG employment, if European standardisation is to be considered it is only as embedded in a larger European work on quality principles (DG Employment) defined at member state level, as in the Open Method of Coordination. This means that if some European standardisation is to be done on those services (Social Services of General Interest), some coordination would be needed with DG Employment.

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For more details, statements can be consulted in the annexes

Some other stakeholder (Social Platform) have interrogations on European Standardisation. Stakeholders may be willing to get involved in the improvement of residential homes services but they are wondering to what extent European Standardisation is the best way to do it. They express some interrogations on European standardisation, calling for some communication on what is a European standard and how it could support quality services. c) Minority: Not in favour of European Standardisation Supporting a quality improvement of services can be done with other means than European standardisation or European strategy for two stakeholders (The Swedish Association of Local Authorities and Regions, USH). Some stakeholders don't see the relevance of a harmonisation strategy as those topics are related to national level and should be handled by member states. The figure below shows the positions of stakeholders. The stakeholders at the right top corner are the ones supporting the European standardisation idea, while the others prefer national strategies (on the left half in the figure) or European directive strategy (in the bottom right corner).

Figure 4: Position of stakeholders regarding European Standardisation in the field 38 of residential homes for Older people

Stakeholders Position Regarding European Standardisation

Standardisation

FIAPA

IAGGS

EDE

AGE

BSI-Consumer

ARODEMS

So cia em

National

SALAR

European

lP lat for DG m plo ym en t

USH ANEC

/ Pour personnaliser les rfrences : EDF

Affichage / En-tte et pied de page

ersonnaliser la zone Pied de page, Faire appliquer partout

Legislation

4.3 Recommendations from Stakeholders

During the European seminar, stakeholders have put forward some recommendations related to the Residential Homes for Older People services sector.

4.3.1 Terminology and classification

There is a need to have a common language! (ARODEMS, Service provider, Switzerland)

Terminology and classification are fundamental standardisation activities that were very positively assessed by stakeholders. For instance, the representative of BSI-consumer underscored the need for a document helping to have a clear view of the diversity and differences of type of residential homes for older people (residential care, nursing homes, sheltered housing, etc.) and their services through Europe. The document could include definitions of the terms and concepts, how they are related, the contexts of use. It has been suggested that such a document could be based on OECD definitions. This document would offer a good basis for further discussions on residential homes for older people services in Europe. The objective of such a document would help reaching an agreement between experts on terms to be used within the framework of the drafting of any document. It would also allow sharing a common vocabulary between customers and providers, notably in a contractual framework.
Considering that there are different variations of residential homes, such as nursing homes or sheltered housing, ANEC would support the development of terminology and classification standards in this area as a prerequisite for any future initiatives. Any such work should take into account the existing standards, guidelines, regulations or other measures, whether at the national or European level. (ANEC Position Statement in Appendix)

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See list of participants for information of stakeholders in the figure

4.3.2 Process
By focusing on the process, a European standardisation document can adapt all countries specificities. (Fondation Mederic Alzheimer, IAGGS)

This proposal has been made by the representatives of FIAPA, of International Association of Geriatrics and Gerontology, and by the representative of Fondation Mdric Alzheimer. Such a document would describe the different stages of the process insisting for instance on the importance of starting by geriatric assessment, how to give relevant information (i.e.: guidelines can be developed to support providers on the way of giving patients information), how to ensure the continuity and coordination of services and care. Stakeholders pointed out such a document could focus on process and would thus not interfere with national regulations. Each country can then develop some guidelines with national specifications/ or national results/expectations.

4.3.3 Characteristics of the service

Describing the minimum requirements of services for European Union countries Some participants explained that in order to protect consumers, there is a need to have a common view of the essential level of service that is to be provided in Residential Homes for Older People through Europe (BSI-consumer, AGE). This suggestion is echoing some needs underscored in the first part of the study (see interim report recommendations). A service requirement standard in the field of services would describe the service in terms of quality criteria and service performance indicators. The purpose is to guarantee, by voluntary process, a minimum level of performance and to initiate an internal improvement process. Describing the Residential Homes for Older People services activity All participants have underscored the importance of sharing good practices concerning Residential Homes for Older People services. All participants also acknowledged the existence of differences among cultural background and resources in European countries. To meet this need, it could be possible to have a flexible frame by drafting a generic standard or guideline for instance. If needed and relevant, this frame would then be a basis for some further developments, i.e. some national documents with more requirements and/or some guidelines at European level. Social life and life environment in Residential Homes for Older people Pr. Moulias (FIAPA) and Mr. Azau (Arodems) underscored the emergency of having European standards to improve the quality of social life within the residential homes for older people. They pointed out that many older people didnt want to come to residential homes because they were afraid of loneliness. Some guidelines could help to encourage active role of users within the establishment, whatever the establishments. Older people could be co-producers of the service and could take part in the everyday life activities taking into account the safety limits. Here again, as for the previous recommendations, a generic standard/document on social life could be developed at European level. It could then serve as a basis at national level to develop more adapted guidelines according to cultures and backgrounds.

4.3.4 Training and competence

Staff competences Although the stakeholders are conscious that the funding of the residential homes plays a crucial role in the level, competence and numbers of employed staff in the sector, Standardisation documents on qualifications and competence are relevant to participants as it is a matter of safety and quality of service, but also of dignity of care with some ethical aspects. European Standard could be considered as a complement, within the framework of national regulations requirements. The stakeholders pointed out some existing documents explaining good practices for instance in the care management field in the Alzheimer field.

They recommended to elaborate guidelines and standardisation documents taking into account, for instance, new competences for fragile persons and for some older people who need special care (more heavy diseases, and mental problems among older people) and to help to support users oriented competence. Importance of volunteers IAGG and FIAPA representatives explained the importance of volunteer work: there are and there will be more and more needs for services to Older people so it is important to take into account the work of volunteers as an important resource.

4.3.5 Standardisation documents about means

A standard focusing on the available/relevant tools to use for delivering some parts of the service (the use of geriatric assessment for instance) could be considered. Association for geriatrics and gerontology pointed out the importance of having instruments and guidelines on how to use them for services providers in order to make an assessment of older people. Tools as forms and documents to facilitate information provision. For instance, there is a need to have information on each countrys practices concerning the information given to users about the service (International Association of Geriatrics and Gerontology). ANEC also made clear suggestions (in the context of a directive) on how information should be provided (transparent, timely, clear, correct and comprehensible information to be provided in accessible formats, information on the service, on the provider, and on the contract and the billing). A tool to support the provision of information can be developed within a standard or in an independent standardisation document. Ethics and code of conduct (AGE) AGE has insisted that residential homes for Older People services have to be approached in a way so that dignity of care matters in the context of long-term care. Ethics criteria or a code of conduct should be developed independently or within a standard on the service.

5 Conclusions and recommendations 5.1 Conclusions

The feasibility study: has confirmed the concern of all stakeholders for improvement of quality of services in residential homes for older people and has allowed to identify the main needs and challenges. It has confirmed that most stakeholders find European standardisation relevant in order to meet those needs and has proposed some recommendations concerning some subjects that could be the object of future European standardisation work in the field of Residential Homes for Older People. The feasibility study has been a fantastic opportunity to gather a lot of information and to put together different stakeholders from several European countries. A common aim was motivating them: the importance 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 their willingness to start working as soon as possible. Some have sent a letter of support for the standardisation project 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 given the high priority of the ageing European population and the quality of services that are to be provided to them, AFNOR recommends that three levels of action can be separately or simultaneously considered. Network Animation (recommendation to both EC and CEN) Support of European Standardisation work (recommendation to EC) by creation a CEN/Technical Committee Communication on European standardisation for Social Services (recommendation to CEN). This would cover residential homes services, home services, family services, childcare services, etc.

5.2 Recommendations

AFNOR insists on the fact that any implementation of those recommendations is to be coordinated with DG Employment on Open Method of Coordination and DG Enterprise. Moreover some coordination is also needed with: The recommendations from the feasibility study on Home Services (M371-Project 4), leaded by AFNOR as those services, as far as they concern elderly care should be treated in the long-term care CEN/Technical Committee. The conclusions of the feasibility study on smart houses services for Elderly and Disabled People (M371-Project 11) leaded by NEN. The conclusion of the CHESSS feasibility study as the recommendations on complaints and redress system should be directly referred with. The Austrian initiative of creating a project committee on Sheltered Housing. The recent creation of this CEN Project Committee shows that there is a need for European standardisation in the field of long-term care.

AFNORs conclusion on the basis of the feasibility study results is that the following next steps should be recommended: 1- Multi-stakeholders forum 2- Organisation of a Technical Committee on long-term care 3- Communication on the role of standardisation of services related to social services

5.2.1 ACTION 1: Multi Stakeholders Forum: Recommendation to CEN and to EU

Description AFNOR recommends to EU and to CEN to support the creation of a multi-stakeholders forum. The creation of a multi-stakeholder group would enhance informal experience sharing within a group form leaded by standardisation representative with some experts animation (same title as TC). This would allow keeping active contacts with stakeholders and exchange on the quality of services for older people through standardisation. This would represent a concrete short-term action in favour of the reflection on the Residential Homes for Older People, as well as an efficient follow-up of the feasibility study. This would strengthen the relationship between European stakeholders (private, public, associative or administrative sector) and will enhance the communication and the elaboration of a shared strategy. This would contribute to a better understanding of European standardisation and of its use to improve the services and to raise the public and professional awareness on the need to share the same rules and tools. This recommendation is strongly supported by AGE who encourages:
"To set up a multi stakeholders forum on quality of home and residential services for the elderly. Such forum should bring together public authorities, service providers (both public and private, profit and non profit making), users organisations, funders and AFNOR (on behalf of CEN), to discuss quality guidelines or standards that could be promoted at European level. AGE is asking the Commission to include this proposal in the renewed Social Agenda as a follow-up to the 39 Communication it published on the internal market in November 2007" .

The advantage of this strategy is that it can be implemented in a short-term period.

5.2.2 ACTION 2- Recommendation to EU: Technical Committee on long-term care for older people with all recommended subjects
Description The consultation offered the opportunity to underscore a real need of having a debate on the older people issue at European level as well as a strong will to initiate some actions. At the moment, there are many initiatives that are started at national levels and they could be a basis for some European Work. This is why, according to the Feasibility Study results and in order to participate in the improvement of the long-term care services to older people, AFNOR would recommend creating a Technical Committee dedicated to this issue. The advantage of such a normative strategy is that it contributes on a coherent way to the management of long-term care services to older and dependent persons. The scope would be the services which are provided to older people and dependent persons and their carers and would include residential homes for older people services as well as the home services 40 related to them .
39 40

See AGE letter in Annex This Action 2 takes into account the result of the Feasibility Study on Home Services M371.

For instance, the draft structure proposal of a CEN Technical Committee on long-term care for older people could be the following:

Title: Technical Committee on long-term Care for older people and dependent persons WG 1 Terminology and classification WG 2 Process of long-term care services to older and dependent persons with a "liaison" with the standardisation structure that would come from the CHESSS project on the complaint and redress system (BSI?) WG 3 Training and competence WG 4 Tools and guidelines (code of practice, how to give information guidelines, etc.) Coordination with NEN smart house project Coordination with ON sheltered housing PC

Figure 5: SWOT Analysis of TC long-term care services to older and dependent persons Strengths Weaknesses Put forward a coherent and integrated strategy No funding available to find innovative solution for the long-term care sector Consolidate a network of stakeholders involved in the long-term care services at European and National level

Opportunities

Threats

Strong support of both Users and Providers Misunderstanding of European Standardisation and ready to start in the service sector, perception that national models are going to be challenged The acknowledgement of some needs and the will and the expertise availability of geriatrics specialists, and platform with European view. High Quality of services in long-term care services are a European priority, for instance (Open Method of Coordination) A lot of national and private initiatives have been reported (can be used as a basis of work within a technical committee)

5.2.3 ACTION 3- Recommendation to CEN: Communication on the innovative role of Service standardisation related to social services
Standardisation on services is new, and so is standardisation on vulnerable people. The feasibility study has shown that European standardisation could be confusing for some stakeholders and could make them reluctant to participate or to accept this innovative strategy in social services. The basis for this work could be the CHESSS work on how to write a service standard (module 1) as it shows the diversity of existing services standards and provides a better understanding of some persistent perception about standards:
Repeated negative opinions underline that service standardisation takes too long, and is an expensive and useless process and, worse still, it is not possible due to the nature of services themselves as services depend on peoples behaviour. Finally you are left with the opinion that standardisation is valid for products but not for services. Such opinions are thought to derive from misunderstandings, lack of dependable information and absence of timely support. Module 1 aims to assess the feasibility of preparing a guidance document that would: effectively help in the drafting process of a new standard for any service sector, providing sound ideas on its possible structure and content, be a fundamental 41 clarification tool for service and standardisation professionals and other stakeholders.

For instance, CEN could have a communication document on Frequently Asked Questions (FAQ) answered on European standardisation related to social services: - What to do if the quality of services requirement is higher in national standard? - What to do if the national welfare state is taking care of the long-term care services? - What is the added value to work at European level? This action would be very helpful for European Community as Standardisation is a precious tool to support the implementation of policy and directives.

5.3 NEXT STEPS 5.3.1 Possible action plan to implement action 1: Multi-Stakeholders Forum
Organisation of first meeting First Meeting could be planned for November 2008 in CEN premises Discussion on the agenda with key stakeholders including: DG Employment, DG Entreprise AGE, FIAPA, IAGGS, etc for instance, one item of the agenda could be a follow -up after the publication of the report. Organisers could draft a program of work that could serve as a basis for further discussions during the first meeting. Sending of information to stakeholders contacted during the feasibility study (use e-mailing of feasibility study).

5.3.2 Possible action plan to implement action 2: A CEN Technical Committee on long-term care
Funding NSB for secretariat of Technical Committee Consolidate the Form A in Annex, drafted by FIAPA and IAGGS during Autumn 2008 Send the Form A to CEN for Member Countries Vote in December 2008 Get the vote results: end of February 2009 Kick off meeting: Beginning of may 2009 First EN standard can be published 3 years later: May 2012 Before that date, the Technical Committee can publish guidelines document on a shorter-term.

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CHESS Module 1 Guidance in the preparation of service standards

5.3.3 Possible action plan to implement action 3: Communication on the role of Standardisation on long-term care services
A survey on the perception of European standardisation for services in order to grasp the main argues related to European Standardisation and the main misunderstandings or success stories on the role that European standardisation had or is having. A communication strategy or campaign could be built on the basis of the finding.

Bibliography
Comas-Herrera, Adelina and Wittenberg, Raphael (Ed). European Study of Long-Term Care Expenditure. Investigating the sensitivity of projections of future Long-Term Care expenditure in Germany, Spain, Italy and the United Kingdom to changes in assumptions about demography, dependency, informal care, formal care and unit costs European Commission and AARP joint Conference on Long-Term Care. 13 September 2006, Brussels, Belgium: The Cross -Atlantic Exchange to advance Long-Term Care. Background Paper European Commission, Directorate-General for Employment, Social Affairs and Equal Opportunities, Unit E2. Joint Report on Social Protection and Social Inclusion. 2007. European Foundation for the Improvement of Living and Working Conditions. Employment in social care in Europe, 2006 Go, Kazuhisa. Industrial Research Dept. The Introduction of Market Mechanisms for Long-Term Care Services - An International Comparison with Implications for Japan. http://www.nli-research.co.jp/english/socioeconomics/1998/li9804.html Legido-Quigley, Helena, McKee, Martin, Nolte, Ellen and Glinos, Irene A. Assuring the quality of health care in the European Union. A case for action. World Health Organization 2008, on behalf of the European Observatory on Health Systems and Policies http://www.euro.who.int/document/E91397.pdf Mestheneos, Elizabeth and Triantafillou, Judy on behalf of the EUROFAMCARE group. Supporting Family Carers of Older People in Europe the Pan-European Background. http://www.uke.unihamburg.de/extern/eurofamcare/documents/nabares/peubare_a4.pdf OECD. Health Division. 2008. Conceptual Framework and definition of Long Term Care expenditure http://www.oecd.org/dataoecd/24/58/40760216.pdf Population et socits. Avril 2008 Comment les personnes dpendantes seront-elles entoures en 2030? Projections europennes .

Interesting Websites
AGE Platform http://www.age-platform.org EDE website-+ http://www.ede-eu.org/En/main.asp?id=4BBC547E IAGG website http://www.iagg-er.org/index.jsp FIAPA website http://www.fiapa.org/pg_acc_pres.php Social Platform website http://www.socialplatform.org/ Health Policy Monitor http://www.hpm.org/index.jsp European Health Management Association http://www.ehma.org/_fileupload/publications/IntegratingServicesfoOlderPeopleA ResourceBookforManagers.pdf Procare website http://www.euro.centre.org/procare/

European Commission and AARP Joint Conference on Long-Term Care in Brussels http://www.aarp.org/ltcbrussels

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