University Grenoble Alpes, France
*Corresponding author:Catherine Gucher, University Grenoble Alpes, France
Submission: October 28, 2022; Published: January 25, 2023
ISSN 2578-0093Volume8 Issue2
Due to increased life expectancy, many people now live to a great age. This new time of existence calls into question the traditional norm of a ternary life cycle, and the definition of public action toward old people. Around this last stage of the life course, we can observe a transformation of public policy. This article analyzes the original forms of local public action and the paradigm shift in institutional normative frameworks for management of long life. It examines the role of three lines of public action-successful ageing, territorial development and technology for health and autonomy-as original basis of the new culture of ageing problems, and as levers of change for the actors concerned.
Keywords: Life pathways-public; Policies-successful; Ageing-territories; Development-technology for health; Independence-culture
In their triple cognitive, normative and instrumental dimension , public policies promote a shared meaning, a “culture” for society as a whole and for target population, those who experience vulnerability (and especially for us growing old) . Through their concrete public action, they implement services and facilities that constitute milestones along the life course of the people they target. The contribution of public policies to the structuring of social periods of existence, and notably the three-part structuring of the life cycle through an institutionalized right to retirement, has been widely demonstrated [3,4]. Moreover, the role of policies, as an experience framework for individuals, mainly through the meaning given to age categories, has also been underlined [5,6]. However, through the recent demographic transitions, and the economic crisis, former age group definitions are being revised as are those of the structuring stages of existence. Some authors are now questioning the institutionalized dimension of life courses, suggesting they should be de-standardized  and could take on a significantly more biographic dimension . Criticism of the disengagement theory of  led to thinking that saw the period of existence where an individual is freed of the social constraints linked to work as a new chapter in life, a period during which he or she could keep their grasp on the world for a long time to come [10,11]. With these evolving ageing theories , the revitalization of old age that took place, alongside social and political transformation and the various economic challenges relating to the demographic shifts underway, contributed to the development of policies focused on “Successful Ageing” . These successful ageing theories  introduced a boundary between active ageing on the one hand and dependent ageing on the other. However, two movements in France have upset this bi-polarization of public policies. First of all, the process of territorialization of public action initiated through the decentralization laws of 1982-83 and the laws of territorial development (1992) have led to the emergence of new social actors. The second wave of decentralization in 2004, as well as the laws of territorial reform in 2014, organize this new division of responsibilities and powers between the central State and renewed territorial entities that are unions of communities. In many European countries, new territorial and actors’ organizations appear as an opportunity to reform the social assistance and long-term care for the elderly . Secondly, the demographic transition addresses a new way in which ageing could potentially support economic development. So, in France, state authorities promoted the launching of the silver economy in 2012. Consequently, an increasing number of actors from different sectors of society and especially of the economic and engineering fields take part in the definition of policies toward elderly . In the general frame of successful ageing, two new patterns– territorial development and the promotion of technology for health and autonomy-appear on the scene of public policies on ageing. In this article, we’ll try to analyze these evolutions. Our research highlights the ambivalent bond between local policies with state policies, arising from the tension between empowering solutions and new public management.
Our paper is based on data from empirical studies carried out in four counties (“départements”) in France-Creuse, Isère, Nord and Savoie1-and interviews performed 1) at national level with authorities responsible for defining gerontology policies (n=7),2) at regional and departmental level with organizations in strategic or financial positions related to gerontology services (n=20) and 3) at local level with actors of social action responsible for delivering gerontology services or working in clinical teams with retired and elderly people (n=16). With this data collected during 4 years in the frame of 2 research programs with IRES2 between 2012 and 2014, we analyzed the “experimental and original forms” of public action promoted at territorial level. At the same time, we try to ascertain the cultural and normative dynamics underlying public policies by questioning the dialectics triggered between a form of centrifugal and institutionalized production of public policies in which the State seems to return to centre stage, and a centripetal process in which the diversity and dispersion of actors support cooperative rather than rival dynamics. Because this article is intended as a synthesis of our research work, we will just mobilize interview extracts to illustrate the demonstration when this seems necessary to make the discussion intelligible.
Thinking about growing old: The influence of state and science
Public powers initially intervened in order to provide a political and social response to a collective need for resources, help and, more recently, care. In addition to the specific needs of a group of people, possibly identifiable according to age, dependency or health criteria, the need to ensure social cohesion, and the problems stemming from the coexistence of 4, if not 5, generations all living together, call for new regulations [17,18]. The question of redistribution between generations and the need to articulate private, family and public forms of solidarity are at the center of political intervention Kohli 1999 . Dependency policies and, more recently, policies targeting Alzheimer’s sufferers illustrate the persistence of sectorbased policies and the tendency to narrow the targeting of the populations concerned. The transformation of scientific categories into categories for public action  is an efficient support for this evolution. Calling on “biomedical” expertise makes it possible to define a tool for identifying and selecting groups of people for whom public intervention is an absolute requisite . An epidemiological approach seems to be emerging in the field of public action with statistics being used to back up public intervention [22,23]. However, this approach does not take into account the dynamic complexity of life courses and interactions between different age groups and generations within society. So, alongside these national care policies, other modes of political intervention are emerging. These aim to promote new lifestyles in old age, notably based on the concept of “Successful Ageing”. The policies in this field therefore no longer target a specifically defined older population but are concerned more generally with the process of ageing and the structuring of relations between the people engaged in this process and society as a whole. Through their highly rhetorical and symbolic dimension , these programs of public intervention help to properly support, both formally and symbolically, the last stage of existence (Walker 2008). In this area too, the direction followed by public policies seems to be closely linked to public health perspectives: Epidemiology is emerging as the founding science of the regulation of social relations and the definition of the meaning of public intervention . The new paradigm, “Successful ageing”, underlying these revised policies, makes common sense for all public action initiators and organizers3. The concept draws its strength from its dual scientific and ideological inscription and its international vocation. The notion of “Successful Ageing” has found its way into discussions about future prospects in all developed countries. The notion of “bien vieillir” (literally “ageing well”), used in French policies, stemmed from the successful ageing theories developed in the 1990s by researchers in the domains of medicine and psychology , and from the active ageing4 theories promoted by economists and political scientists in the 2000s5. The knowledge upon which successful ageing theories are founded is partly scientific but also comprises a normative and ideological dimension, which might be assimilated with a form of state “policing”. Medical and psycho-social research presents successful ageing as the result of lifestyle choices and adaptation strategies as individuals grow older . These strategies for selection, optimization and compensation make it possible to maintain and take advantage of remaining potential while adapting to inescapable transformations. Medical approaches highlight three factors determining successful ageing: A low probability of falling prey to disease or disability related to illness, a high cognitive and physical functional capacity, and active engagement in life . However, some researchers have underlined the unexpected effects of the media coverage received by the concept , as well as slippage towards a normative rather than scientific dimension. One example of this is the way the notion has come to be associated with the liberal “activation” strategies underlying European social policies over the last 20 years Bucur 2012 .
By introducing measures to the social compensation of certain social risks, the new forms of social policies are based on the definition of an autonomous individual who is responsible for the course of their own existence. At the same time, however, they contribute to the “denial of recognition” by channeling norms that violate the forms of thinking and existence of certain groups. The value of individual responsibility in life course management is thus emphasized and the policies developed are positioned as facilitating the expression of this individual responsibility. Furthermore, the activity-good-health debate is at the heart of this concept. Added to this are the dynamics of exchange relations upheld between generations and a process of continuous social participation (Walker op.cit.). In 1999, the European Commission drafted a large programme of actions targeting active ageing in order to build “a Europe for all ages”. Focusing on employment, training, work exit facilities as well as the organization of the social and health management system for the very old, the programme helped to redefine the different periods of life, along with their limits and their functions. It thus appeared to be able to render life courses more flexible. Although the political effects of active ageing theories seem to have disappointed the promoters of these theories (Walker op. cit.), they have nevertheless found their way into social action policies targeting retirees and the elderly and help to structure the last stage of existence in a genuinely normative way. Nevertheless, this new public action paradigm, which has found consensus among most actors of gerontology organizers has not supplanted the biomedical paradigm that structures dependency management public action. Both paradigms convey new alliances between scientific and state spheres, leading to the emergence of a form of intelligence6, i.e., of a sphere of elite promoting scientific and technical activity to be used by the state in policy-making. Yet, at operational level, these two movements are generating segmentation in the fields of action and among the organizers. On the way to successful ageing, reforming of actions perspectives based on prevention, participation and responsibility. In France, as part of the institutional restructuring introduced by decentralization, pension institutions and social welfare groups (GPS7) have concentrated on developing new perspectives of action . These aim to make people more autonomous and empower them to manage their life course to ensure “successful ageing”. They can thus be seen as a form of support for de-institutionalizing life course management. “For us, up until now, social action was about helping people financially: if they had a problem, became widowed or something untoward happened to them over the course of their life, we had to be able to intervene on the spot, but financially. And, in fact, we realized that with people growing older, or suffering disability, we also had to act, but earlier on. It was our duty to prepare people ahead of time, to anticipate…” (GPS interview n°3). These actions therefore aim to guide people through transitional periods and the trials of existence. Today, instead of targeting a specific population, they are geared towards developing the right social conditions for the last stage of existence. “Between the two (social action and societal action), we provide assistance with collective projects or service actions: Actions targeting prevention, conferences… for our beneficiaries when they join us and as part of the joint AGIRC ARRCO8 programme… Social action is about helping people through the accidents of life, it does not fall within a legal framework of entitlement.” (Interview GPS n°1 AG2R9). The educational dimension is now well entrenched in these new forms of intervention, whether these are developed by public actors-local authorities or state departments–or by private actors involved in the concrete implementation of public policiespension funds, insurance organizations or social welfare groups. Already very much present in public health approaches, this perspective is also making itself felt in the field of social action with the blurring of boundaries that has emerged since the definition of a set of social healthcare skills for regional health agencies. “In social action, there isn’t just the financial aspect, or the monetary aspect that is involved, there is also the guidance and advice factor that is important”. (Interview GPS n°2). Local public actors share these goals that seem to promote more positive approaches to old age. But at the same time public institutions develop normative thinking and assert the individual responsibility of each person on his individual life course. “We need to put a stop to the excessive mothering involved in social action. Older people need to be helped, not mothered and their families should be educated in this aspect. Social action is simply an answer that makes everybody feel safe!” (Interview, CLIC10 Nord). Prevention has become the leitmotiv of all these actors. It is seen in the sense of preventing situations of dependency or diseases relating to old age from occurring. The reference to “successful ageing” is thus highly explicit and the norms of autonomy and empowerment have now imposed themselves as structuring frameworks for the end-of-life pathway. In another way, the perspective of promoting social participation for elderly and making them autonomous is furthered through the international program “age-friendly cities” . The World Health Organization (WHO) promoted the Global Age-Friendly cities guide in 2012. Eight domains of urban life are concerned by this initiative: Outdoor spaces and buildings; transportation; housing; social participation; respect and social inclusion; civic participation and employment; communication and information; and community support and health services. Furthermore, an international network “Réseau francophone villes amies des aînés” was created and a specific guide adapted to French realities published. Consequently, many cities in France, as for example, Dijon or Grenoble, have revised their policies toward old people. This program is based on a new conception of making public policy: Thinking and acting for the elderly with their contribution.
The first degree of social participation is the citizen’s association with the policy process. Focus groups with people aged 60 years and older are organized in different areas of a town. Additional focus groups are held in most sites with specific target people, as old emigrants or poor people and also interviews with caregivers and service providers, volunteers… consequently, different types of intervention contribute to standardizing living environments, making them compatible with the day-to-day difficulties linked with growing old. However, in VADA process the most important objective seems to be the contribution of elderly in the public space toward social interactions and cohesion (Walker 1999). They are called to be, for a long time, real active actors with other generations in the social activity of the city. Many years ago, “activation” became a leitmotiv in social policies. This new paradigm, first concerned with labour policies, today involves all social fields and is addressed to all target people, who must be active . Successful ageing and VADA process could be considered as the translation of this paradigm in policies for elderly. If some portions of the elderlythe most graduate and comfortably off-agree to this perspective, for others, with disability or living precariously, this manner of envisaging public policy contains a risk of exclusion . Generally speaking, these policies seem to provide individuals with control over their lives . They empower people to orientate their life course in a positive direction in line with the idea of “successful ageing”. It is only when they are pronounced dependent that they can be liberated from these exhortations of self-protection, if not self-repair. When this is the case, “care” schemes are put in place. These ensure that their career of dependency11 is managed materially, through assistance and care systems and pathways. The consensus of actors in relation to the concept of “successful ageing” and the blurring the boundaries of both contribute to this freshly normalized socio-cultural life model for the elderly. Locally, two justifications are evoked for this procedure: First of all, the territorial development in its economic, cultural and social dimensions in order to protect social cohesion and secondly the design and promotion of technology for health and independence, which instates old people as autonomous and economic actors. Territorialization as a key factor of ageing policies. With territorialization, renewal of the strategic configuration of actors, redefinition of areas of expertise and of the boundaries of intervention. Over and above the reforms of State action (RGPP12, LOLF13, etc.) which contribute to initiate a “new public management” [36,37] and “redefine the norms of public action according to economic logic” , decentralization14 was based on the argument as to the necessity to focus on greater proximity between the political sphere and those targeted by its action, with the aim of establishing a better match between political measures and the local population’s needs (Lefebvre 2006). Another argument was economic and concerned with efficiency. The question of the State’s rational efficiency is at the core of political science analyses in Europe as well as in Anglo-Saxon countries . Thus, the new directions followed by public policies in France have placed the State in a role of manager  and magnify cross-cutting and regionalized approaches15, generating substantial mutations in the public policy for the elderly. The laws of decentralization, and those that led to the creation of a personalized autonomy allowance in 200116 were behind an extensive reshuffling in the positioning of actors in charge of old age. Care for dependent individuals was left to the authority of departmental councils (Conseils Généraux)17, who are notably in charge of evaluation and allocation of the personalized autonomy allowance. This monopoly exercised by county councils when it comes to the question of dependency causes a search for new positions and responsibilities for other initiators of public policies for the elderly. These promoters of support for the last stage of existence, historically present in the implementation of gerontology policies–community centers for social action in municipalities (“Centres Communaux d’Action Sociale”)18, and pension fund organizations–have had to redefine their scope of action. “When it comes to the elderly population, there is indeed a sharing out in terms of management: The county council is in charge of dependent people and CARSAT and MSA19 are in charge of prevention.” (Interview, CCAS Nord n°3). Historically in charge of leisure time and home help, pension institutions have adapted to demographic, societal and economic changes as well as to the requirements imposed by decentralization and the APA allowance law. They have progressively and partially disengaged from the financing of home help. Their actions now target more the physical and human environment of older people together with that of their family careers even when they are not direct beneficiaries of their funds. What can be seen here is a slippage between the two paradigms for public action targeting the elderly: Dependency versus successful ageing. It can also be seen that economic issues (resources, access to leisure activities) have disappeared in favor of the concept of successful ageing. The old principle governing the intervention of pension institutions, founded on the notion of entitlement, has been replaced by the targeting of a category defined according to biomedical criteria, in relation to the distribution of skills between actors, decided at state level, and through the redefinition of collective action prospects that do not only target entitled beneficiaries. Municipalities appear to be less subject to imposed requirements in the redefinition of their areas of expertise. Long engaged in the organization and management of services designed to provide care for the elderly, including the question of dependency, they continue to manage catering, home-help and home-care services that greatly support the assistance schemes determined as part of the APA system by the medical and social teams working for county councils. The new “successful ageing” paradigm does not appear to be at the center of the concerns of these historical social actors who are more focused on providing support and care through the development of optional assistance and collective services. It would appear that although the question of dependency is behind a clear segmentation of actors’ roles with respect to the management of the system in charge of organizing support for dependent individuals and the ordering of home help, the implementation of assistance schemes still relies greatly on other actors in the area of gerontology, such as the CCAS or associations who are still a have considerable autonomy in the way they design and provide their services. Our empirical studies have led us to think about the positioning of actors in the field of gerontology policies not only as stemming from an organization thought up by the central state government but rather as a social configuration resulting from local combinations. Forms of autonomous regulation, far removed from state institutionalism and the conceptual frameworks of public action, can be observed in the operational structures engaged in local action. These systemic dynamics are similar to those highlighted by the Steuerungstheorie .
In addition, the topic of “successful ageing”, generally understood to mean care for vulnerable older people and the need to develop prevention actions, relies on cooperation between a number of institutional actors. Our field studies clearly show that prevention actions–such as assistance for careers–are the result of cross partnerships involving numerous social and medico-social actors: pension funds, health insurance organizations, county councils, municipalities etc. The new principle of the territorialization of public action has changed the rules for designing the action of certain operators. Thus, pension funds, health insurance organizations or social welfare groups who, by definition, used to design their action for their own beneficiaries are today targeting a much larger population including all retirees in the territory concerned by public action. These observations question the durability of thinking based on social rights following on from the territorialization approach developed since decentralization . The ultimate question concerns how to secure end of life trajectories by guaranteeing specific rights. Similarly, the missions of the new Regional Health Agencies, set up in accordance with law n° 2009-879 of 21 July 2009 on hospital reform and relative to patients, health and territories (referred to as the HPST law) and law n° 2016-41 of modernization of our health system, question the separation of the distinction between the two spheres of social action, health and medico-social sector. The aims of the departmental scheme for ageing policy and those underlying the regional medico-social organizational scheme (SROMS) of the regional health project drawn up and set out by the Regional Health Agency director, are in line with each other in regard to dependency. There are also new forms of cooperation that underline the blurring of former boundaries between the health and social sectors. “We’re going to set up health and medicosocial cooperation groups between hospitals and nursing homes. This is a legal formula that allows resources to be pooled. We have a cooperation group bringing together three SSIADs [nursing care and home help services]: Shared management and an organization that is pooled and optimized in relation to distances. We’ll have a shared management team for the hospitals and the nursing homes. It’s very difficult finding people to fill nursing home manager vacancies. Perhaps this way we’ll have more people applying.” (Interview, Regional Health Authority). The territorialized social schemes have led to new working methods that help to break down separations and encourage cross-cutting management and social intervention [45,46]. These new modes of action, more visible in rural areas than in urban areas, partially prevent actors from being compartmentalized and the last life stage from being segmented. The multi-positions of actors and their shifting between different public and private health and social spheres have led to the reconfiguring of public action. This action has become increasingly dispersed even though it has continued to abide by the paradigmatic frameworks governing it. Another consequence is the redefinition of the State’s role  On the other hand, the forms of action can be seen to be more homogenized and unified. With this comes the risk of consensually normalizing the way the very old should live the last stage of their existence. This risk is all the more worrying given that territorialization involves close control over populations, a control that is exerted by intermediary agents20. But institutional fragmentation encourages an accumulation of specific programs, which are also a guarantee of possibility of choice and autonomy for the elderly.
For the last twenty years, town and country planning approaches have fostered the emergence of schemes based on the grouping together or creation of new local actors, notably in rural areas but also in urban environments. Associations of communes (“syndicats intercommunaux”) have progressively and partially given way to communities of municipalities then to district authorities, the stated aim being to define genuine territorial planning projects. Various tools have contributed to the development of territorial policies such as global development contracts, regional local development contracts, district contracts, etc. These tools are designed to move beyond traditional sector-based action modes now considered to be inapplicable [49,50]. In urban territories, new skills for conurbation committees (“communautés d’agglomération”) have been defined while local democracy models, especially at neighborhood level, have been revised and new actors have also appeared. This organization can also be understood as a transformation of the mid and lower public sector into a new space for innovation and development on an entrepreneurial basis (Minas & Overbye op.cit.). The control of the centre is operational and financial and takes effect through calls for projects and contracts for aims and means . The new approaches have led to the appearance, in political arenas, of new territorial actors involved in public action and to the emergence of new political concerns about ageing. Social assistance schemes have been transformed with the territorial reorganization. Two focuses appear to co-exist at territorial level: alongside the traditional focus on social assistance and medical care for the elderly, occupied mainly, from now on, by department councils, there is a new focus on the development of geographic and social areas to meet the needs of the ageing population. In rural areas it is also a means of fighting against isolation and supporting relationships between generations . The projects developed in line with “local planning” objectives group together social, healthcare and medical actors, in new forms of inter-municipality cooperation, they also associate specific town and country planning actors, and even bodies involved in tourism such as regional natural parks. The projects sometimes focus on rural areas as part of Centre of Rural Excellence (CRE) via calls for projects at European level or Leader projects21 supported by the EAFRD. The small Life Units (PUV) project, together with that of the health center network in the territories of the Upper Creuse community of municipalities and the Millevaches regional natural park, illustrate the positioning of new actors. It revised modes of public action targeting the combined use of the different skills and resources of all actors in the area, as well as complex actions aiming above all to re-energize the rural area. “We used the CREUSALIS construction, a council housing office in the Creuse. But we needed financing. To find the money, we decided to apply for a CRE22 [grant] for financing and help with a structure split between the two[territorial] centers, 10 housing units+10 housing units and 2 leisure rooms… And so, we designed these PUV23 with the county council helped by the CRE project engineering. The community of municipalities didn’t have the staff to lead the project. We had to have people who knew about loss of autonomy… Otherwise, we would have had to have a design office. It was an original project, in line with the area and its resources. The link with the MSA that had initially coordinated the project remained. We set up a steering committee… The objective is to keep the elderly people there and in the center of town for as long as possible. People can thus come closer to the town centers. We also have a health and autonomy project. We applied for another CRE grant, which was also accepted. It was led by the Millevache CRE. It’s a nursing center project. Each housing unit will be next to a health center. And we’ve also coordinated a health and autonomy project led by the regional health authority and the Millevache regional natural park: it’s another CRE project. The regional health authority asked the regional natural park for help with the diagnosis of health needs and construction of a local health network in the Limousin mountain area. The community of municipalities is in charge of the premises for this project. The idea is to build 5 sites for health centers where private doctors, nurses and physiotherapists will be able to work on the premises made available by the authority. For each housing unit project there is a health center 60 per cent of whose financing comes from the CRE. (A health center costs € 400000). That will also make it possible for Clermont practitioners to come and run consultation days… All of these projects mean that 1) health professionals stay in the area: They are sure to have patient and better working conditions and that’s important so that the local population doesn’t leave the sector and to attract families with children it helps to have doctors in the area. 2) There’s the support for the economy and shops, we’re supporting local trade, and 3) there’s the support of local activities through different events… I think that in the future we should promote a. These development policies have provided actors who had remained on the fringe in terms of elderly policy decentralization with new opportunities to revise their positioning. They have also encouraged the emergence of new representations for the populations living in these areas. Older people are no longer considered exclusively from the point of view of their medico-social needs (i.e., as users of care and assistance services) but as inhabitants able to take part in an economic revival process . The actions developed are grounded on the idea of satisfying the economic, social, cultural and healthrelated needs of the whole population of an area. The age friendly communities’ paradigm is also a support for the invention of new forms of public actions which envisage ageing as an interaction between people and their environment. Retirement, ageing and old age are hence no longer thought of as specific situations, clearly limited by administrative, age-related or dependency criteria but as stages in the dynamic life process of the inhabitants of an area . This reference to territory appears to authorize “longitudinal thinking” about ageing and old age, thinking that allows a different definition of problem situations, for which public intervention has to be justified. Territory is analyzed as a factor mediating ageing experiences and opportunities . These initiatives also seem to support new end of life care trajectories far removed from the standards contained in medico-social policies for the elderly. Furthermore, territorial development policies open the field of gerontology for new actors, who consider old people as a potential for social cohesion and development
A tendency toward marketization of social needs?
Since 20th, the State government in France has tried to encourage economic actors to develop the “silver economy”24 and form a specific sector of activity: to limit public social expenses, the market would be a solution and perhaps become involved in policy . From the policy perspective, these solutions could support safe independence at home and could be a cost-effective option . For Coughlin, it will be necessary in the future, to develop a strategy for policies which includes “two sets of activities: Create new or restructured institutions that will administer technology and ageing policies and implement policies that will set the agenda, stimulate the market and ensure technological equity. “(Coughlin ibid: 59). The example of France shows how the policy scope coincides with the creation of new para public organizations; these latter take a large part in the implementation of technological solutions in the home care services. The promotion of technology for health and autonomy relies on an abundant production of reports and other grey literature, for the most part produced by geriatricians or technologists. In 2007, a national structure for this new sector of activities was created with the support of scientific societies: The French Society for Autonomy and Gerontechnology (la Société française de technologies pour l’autonomie et gérontechnologie (SF-TAG). This initiative found support from the International Society of Gerontechnology, created in 199625. Continuing on from these orientations, a national reference center for technology for health and autonomy was created in 2008, and in 6 regions of France local centers were developed. These initiatives generally involve a synergy between hospitals, local industries and universities. These initiatives on the part of the government produce an increasing interest in health and social needs in old age, in the technical field. A few big traditional operators in the telecom sector invest in research and development for e-health solutions. And we can observe the birth of many start-ups, who believe in the potential of the market for seniors. The national foundation for solidarity and autonomy (CNSA) declares a willingness to highlight the market for technical aids and improve their use by all populations subject to loss of autonomy (ALCIMED, Caisse Nationale de Solidarité pour l’Autonomie, 2007: 45) through the creation of the national observatory for the market and prices of technical services. In 2012, the national Council For Economy, Industry, Energy And Technology (CGEIET), was created. Its aim is to support the implementation of gerontechnologies in home care services through scientific contributions and to give some rational support to the development of policy in this area. Thus, a technical economic network has grown beyond the boundaries of traditional areas of action in gerontology, legitimating recognized skills frameworks and putting into question the contours of the spheres of legitimacy of public and private actors [58,59]. The scientific and technical poles have already entered in synergy since the 1990ies through the alliance of geriatrics and innovative industry, but the market remains unexplored due to the limited interest of old people and social and medical workers . Through the definition of a new area of intervention for public action and the legitimation of actors now recognized for their expertise, the State is redefining the issues for old age at the intersection of economic development and health and social needs. Turning its back on social gerontology, a new socio-industrial approach to the problems of old age has formed, with a parallel evolution in the provision of home care services . Thus, the social needs of old people must find new responses via the market. Via this process old people become consumers rather than individuals in need of care . In line with these new representations of old age, public policies have been transformed through market-related reforms in social care and the national or territorial authorities change the way their work by regulation instead of leading initiative. This evolution opens a new path for public action towards the elderly based on two simultaneous dynamics. One hand, the top-down process initiated by the government, which promotes technological innovation in the field of ageing thus legitimating new actors in the development services for the elderly. On the other hand, a bottom-up process: Local initiatives help to encourage new forms of thinking the social needs of elderly and to develop new ways of working together in «consortiums», where the public sector and the commercial sector would mutually adjust their cultures. These dynamics act on the professional field of ageing and aim to transform it. A healthy home needs communication with family, for disability and also health monitors should be a major focus for technology research.
A new culture in acts?
In France since the year 2000, parallel to the governmental strategy which promotes the market of new technology, we can observe the increase at the territorial level of projects developed experimentally. Administrative decentralization seeks to redistribute the responsibility of thinking and acting about ageing problems. In the frame of new public management semi-autonomous public authorities or corporations take part in the planning and management of public functions . These reforms seem to be supported in the case of ageing policies by the development of the silver economy26, which aims to develop gerontechnology as new support for home care services. These public decisions make a large place for technologists and commercial actors in the field of ageing. A percentage of solutions for dependency would be delegated to profit organizations, in relation to departmental authorities, introducing competition and profit in the social field. At local level these new actors assert their expertise in the field of health and autonomy and challenge the right of social actors to define the problematic of ageing. They fight to establish their hold over the training, expertise and the projects which are decided by politics . The departments as pilots for ageing policies  are mobilized to find new cost-efficient solutions for the elderly. The expert centers for gerontechnology, which are at local level, and serve as relays for the national reference center, appear to be good supports in this way of implementing policy. In projects such as DOMO Creuse (Creuse department) or ISERE’A DOM (Isere department), these innovators take the lead under the aegis of department and bring together traditional public actors for gerontology (pension funds, town councils, hospitals, social services,…) and private actors such as start-ups and industries… These projects are usually largely experimental or serve to demonstrate the possibility of rethinking policy in this area. Some of the proposals concern the networking of actors, the integration of health and social services through the use of ICTs or the provision of devices like fall detectors, electronic pill boxes, electronic monitoring (GPS) bracelets associated with direct services to the people. We can note the new forms of action for the departmental authorities: The implementation of competitive dialogue in the organization of a private-public consortium in the frame of Isere’ A Dom or even a public service delegation as part of the project DOMO Creuse. Through these various initiatives, the transformation of systems of actions operates under the control of departmental councils, which implicitly expresses a claim of “property right” in redefining problems linked to old age. The concepts of performance, the streamlining of action and the control of human activity and the costs it engenders, are at the heart of political decision-making. Some of the instruments of business management, in the industrial sector, become modes of governance in public affairs. Based on a “social-industrial” model  a medico-technical paradigm is emerging through new interactions between social worlds which become closer by the mediation of the politics at the territorial level. The dialogue power/science and technology initiated at the national level, is a lever to be taken into consideration in the management of bodies concerned by frailty or disability. This paradigm is expressed through the registers of language, the repositioning of actors and forms of actions. In this sense, territorial action around issues related to the adaptation of the habitat typically take the form of the redefinition of the problems of old age in technical terms through the positioning of privileged actors, such as teams of occupational therapy professionals and housing and construction professionals. These initiatives move the previous distribution of roles and competences between social and medico social, private and public action field. New interactions are the result of technological creation involving diverse actors from the “world of science, technique and (the) market”, and public action . These experimental relationships are based on the mutual acculturation of the organizations involved and are based on propositions formulated by the holders of public action. But these initiatives contribute a turn away from social gerontology and to the development of a new socio-industrial approach to the problems of ageing. These new modes of action make it difficult for any traditional social actors to maintain their role in the definition of new services for the elderly . This new culture of public problems is based on new worlds of sense, adopted by the actors of the technical and economical network developed on the initiative of the State. The political will is to make ageing “a source of positive economy”. Seniors are now considered as a potential locomotive of economic gain for our societies when they support the development of services and technological products to live at home . (Mission letter for the document Vivre chez soi, Pr Franco)27. This double social dynamic production and legitimization by the State government of a system of action and the rethinking of frameworks-that give meaning and regulation for new initiatives, invention, experimentation, by new local actors at territorial levelparticipates in the formation of the new culture of public problems of old age (Gusfield, op. cit.) .
As a result of our research, we can confirm that end of life care trajectories is being addressed through very different policies and complex combinations . First and foremost, it appears important to underline the normative dimension of the “successful ageing” and “dependency” paradigm, which is uniting the actors involved in the design of national policies based on a strong consensus. This bipolar paradigmatic articulation has led to a clear segmentation of the expertise and intervention areas of the divers’ actors. Based on these notions, care and support modes, structures and specific schemes are being developed to organize the last stages of existence. It seems possible to claim that the end-of-life trajectory is constructed through orchestrated transitions in care provided first through the social field-social action services provided by welfare and retirement institutions-moving on to services belonging to the medico-social field-county councils-and coming to rest in the field of the health sector. This orchestration of the stages of the end of life thus stems from a certain form of medicalization of old age and of the term of existence . Yet, alongside these general frameworks for thinking and action that we have underlined, it also seems that territories are, to a certain extent, applying their own interpretation of the organizational frameworks and normative dimensions of the policies promoted at national level. The definition of actors’ positioning according to the official distribution of fields of expertise is affected by substantial adaptations at the local level. New operators (communities of municipalities, regional natural parks, etc.) have appeared and are contributing to the organization of the end-of-life trajectory, while traditional operators have agreed to share their field of intervention with other actors (CCAS, county councils, pension funds, etc.) with the aim of pooling resources and means as they strive towards a common goal . The boundaries between health, medico-social and social fields have become considerably blurred since the definition of the regional health agency. Furthermore, a new paradigm seems to be laying the groundwork for new conceptions of care and for end-of-life policies: What we refer to here as territorial identity. The use of the notion of territory, supported by shared identity and the ideology of being at home, has authorized a restructuring of the categories justifying public action. Age and dependency have been left to the decentralized medico-social policies while new classificatory items are appearing. Retirees and older persons are thus considered and renamed according to their relationship to the territory and its development. Moreover, the development of a policy for health and autonomy technology introduces actors from the technical sector into the field of gerontology . This development contributes to the transformation of the art of making local policy with new governance and a tendency for marketization of the social and medical needs of old people. Thus, the elderly become consumers, as such they are considered as a potential support for the economy. These new local policies founded on the promotion of new paradigms, far removed from sector-based logic, notably owing to the renewal of the actors at their head and their ignorance of medico-social fields, are at the root of a positive restructuring of the forms of user categorization and a renewal of the inclusive approaches promoted by the elderly polices from the 1960s through to the 1980s. To conclude, end of life care policies is characterized by contrasting and paradoxical dynamics . These involve both the shaping of normative pathways for the elderly through to the end of life and the environmental developments that undoubtedly facilitate the biographic constructions of end-of-life trajectories, as long as these are strongly grounded in the local environment or territory.
© 2023 Catherine Gucher. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and build upon your work non-commercially.