France’s Long-Term Care Workforce Crisis: Recruitment, Retention, Pay and Professional Recognition

France’s ambition to enable more people to remain at home, improve EHPAD quality and respond to rapid population ageing ultimately depends on a resource that cannot be created by legislation alone: enough skilled people willing and able to work in long-term care. An APA support plan has limited value if a service autonomie à domicile cannot recruit the worker needed to deliver it. An EHPAD can have strong clinical procedures yet still struggle to provide continuity if nursing, care-assistant or coordinating posts remain vacant.

The workforce question therefore runs through the entire France Ageing, Long-Term Care & Community Support system. France has introduced salary increases, professional-recognition measures, training investment, mobility support and new territorial recruitment initiatives. Yet these measures operate against a deeper structural challenge: the number of people needing support is rising while many care jobs remain physically demanding, relatively low paid, organisationally fragmented and difficult to reconcile with a sustainable working life.

The scale of the future requirement is becoming clearer. DREES projections published in 2026 suggest that supporting older people with loss of autonomy could require roughly 150,000 to 200,000 additional jobs by 2050 simply to provide basic care at home and in institutional settings, depending on how France develops EHPAD capacity and alternative forms of housing.

This is not simply a recruitment campaign challenge. France must decide how long-term care work is funded, organised, valued, trained, distributed and governed. The distinction matters because attracting people into a poorly designed employment model will not solve a retention problem.

The Workforce Challenge Is Structural, Not Temporary

Recruitment pressures in French elder care pre-date the pandemic, although Covid-19 intensified them and exposed their consequences more visibly.

Aides-soignants, infirmiers, aides à domicile, accompagnants éducatifs et sociaux and EHPAD medical coordinators have all been identified as professions facing substantial tension. Employers compete not only with each other but with hospitals, other health and social-care sectors and entirely different industries offering more predictable hours or less physically demanding employment.

The difficulty is particularly significant because demand is not static.

France’s oldest age groups are expanding. More people will live with frailty, dementia, chronic illness and multiple conditions. Policy simultaneously aims to support people at home for longer, which changes rather than removes workforce demand. A shift away from institutional care means more professionals travelling between dispersed homes, managing complex situations independently and coordinating with health and social-support partners.

DREES modelling illustrates the scale of that interaction. If EHPAD capacity were broadly held at current levels while more people remained in ordinary housing or intermediate accommodation, the number of older people receiving APA at home would rise substantially by 2050. Home-support employment would need to grow with it.

Conversely, expanding EHPAD capacity requires its own additional workforce.

The strategic question is therefore not whether France needs more workers. It is where they will work, what skills they will need, how those jobs will be financed and how the system prevents one part of the autonomy sector from solving its recruitment problem by drawing staff away from another.

This is why workforce planning needs to sit alongside demographic planning rather than follow it several years later.

Home Care Faces a Distinct Labour-Market Problem

The workforce pressures experienced by services autonomie à domicile are not identical to those faced by EHPADs.

Home-support professionals work across dispersed locations, often travelling repeatedly during the working day. Some schedules contain split shifts around periods of greatest demand in the morning and evening. Travel time, transport costs, short interventions and gaps between visits all shape whether a nominal hourly wage produces an attractive working day.

Professionals may also work alone in people’s homes, dealing with changing health conditions, family dynamics, safeguarding concerns and emergencies without immediate colleagues nearby.

The job therefore combines relational skill, practical care and significant autonomous judgement, yet historically has often been perceived as low-skilled work.

That mismatch between responsibility and recognition is central to the attraction problem.

France has sought to respond through several mechanisms. A major restructuring of pay and job classification in the associative home-help branch took effect in 2021 through Avenant 43, producing significant average increases and giving greater weight to skills, experience and responsibilities. Subsequent collective-agreement changes have continued to refine classification and employment arrangements.

The 2024 bien vieillir law also introduced a professional card for qualified home-support workers, effective from January 2025. Eligibility is linked to an appropriate professional certification or substantial relevant experience. The measure is partly symbolic but also practical: it formally identifies qualified professionals and is intended to facilitate aspects of their work, including mobility.

The same law created CNSA financial support for départements to improve professional mobility, including transport assistance and, where appropriate, help obtaining a driving licence.

That is an unusually concrete workforce intervention because transport is not peripheral to home care. In many territories, a service cannot expand merely because demand exists; it needs workers who can physically reach widely dispersed homes.

Operational scenario: A rural service has vacancies but transport is the real constraint

A service autonomie à domicile in a predominantly rural département receives increasing numbers of APA plans requiring morning personal care. It advertises repeatedly for aides à domicile and attracts several applicants, yet two promising candidates withdraw because they do not have reliable access to a vehicle.

The immediate problem appears to be recruitment, but the operational evidence shows something more specific. Existing staff already travel substantial distances between visits. Expanding their routes further would create additional unpaid gaps, late arrivals and excessive working days.

The département and service therefore treat mobility as part of workforce capacity. Assistance linked to professional travel and driving access is explored, route design is reviewed and recruitment campaigns are focused on geographic clusters rather than simply increasing the number of advertisements.

The service also examines whether schedules can be constructed around longer blocks of work instead of fragmented short visits.

The lesson is important. A vacancy count alone would have diagnosed “not enough applicants”. The deeper workforce analysis identifies transport infrastructure and job design as the barriers.

Once that information reaches territorial decision-makers, the response can move from repeated recruitment activity towards a more sustainable local workforce model.

Pay Reform Has Improved the Position but Has Not Removed the Attraction Gap

France has invested heavily in salary revaluation across health, social and medico-social employment since the Ségur de la santé reforms.

EHPAD employees in different parts of the public and private sectors benefited through different legal and collective-agreement mechanisms, while the home-help sector received its own substantial reforms. Government estimates have placed the cumulative public financing of social, health and medico-social salary revaluations in the billions of euros.

These measures matter. Low pay cannot be treated as a secondary issue when jobs involve intimate personal care, night and weekend working, infection risks, lifting, emotional labour and responsibility for people with significant vulnerability.

But headline wage increases do not fully determine whether a job is attractive.

For a home worker, the relevant question may be monthly income after fragmented hours, travel and vehicle costs. For an EHPAD aide-soignant, pay must be assessed alongside workload, staffing levels, shift patterns and opportunities to progress. For an experienced worker, professional recognition includes whether additional competence brings meaningful responsibility and advancement rather than only incremental pay progression.

France’s employment landscape is also fragmented.

Workers may fall under public-service rules or different collective agreements depending on whether they work for a public, non-profit, associative or commercial organisation. Measures introduced for one segment do not necessarily translate identically into another.

This can make “the salary of a French care worker” a misleading concept. Two people providing broadly comparable support may have different pay structures, allowances, career frameworks and employment protections.

The policy challenge is therefore not simply further revaluation. It is building sufficient coherence that long-term care can compete for workers without creating damaging internal inequalities.

Retention Depends on the Daily Reality of Work

Recruiting someone into elder care is only the first stage of workforce sustainability.

The CNSA explicitly identifies difficult physical and psychosocial conditions, split working hours, low pay and weak recognition as continuing pressures within the autonomy workforce. These factors affect absence, occupational injury, burnout and willingness to remain in the profession.

Physical risk is substantial. Moving and supporting people with reduced mobility can create musculoskeletal injury, particularly where suitable equipment is unavailable or workers are under time pressure. Home environments add complexity because they were designed as private residences rather than workplaces.

Emotional demands can be equally significant.

Professionals develop relationships with people who may deteriorate, experience distress or die. They may encounter family conflict, loneliness or safeguarding concerns. EHPAD staff can experience repeated bereavement alongside high-intensity personal care.

Improving staff wellbeing and engagement therefore requires more than wellbeing campaigns. It involves staffing, equipment, supervision, team relationships, predictable schedules, professional autonomy and the opportunity to discuss difficult practice.

The CNSA’s current quality-of-working-life programme recognises that organisational design matters. Its 2025–2027 fund addressing occupational injury supports medico-social services and establishments to obtain equipment that reduces harmful manual handling and associated physical strain.

This illustrates a broader principle: retention expenditure should not be separated from capital and service-design decisions. A ceiling hoist, suitable vehicle, digital scheduling system or redesigned workflow may have a workforce effect as significant as another recruitment campaign.

Operational scenario: Recruitment succeeds but retention begins to deteriorate

An EHPAD has successfully recruited several aides-soignants after a prolonged period of vacancies. Six months later, managers notice rising sickness absence, requests to reduce hours and two resignations from relatively new employees.

The establishment could treat these departures as evidence that the labour market remains difficult and restart recruitment.

Instead, it examines the pattern. Staff feedback shows that the greatest frustration occurs during morning care, when several residents with high dependency require two-person assistance at similar times. Absence frequently leaves the remaining team trying to absorb the workload, while access to some equipment is inefficient because it is shared between different areas.

The solution is therefore not simply another vacancy advertisement. Deployment is redesigned, equipment availability is reviewed and the establishment strengthens short operational debriefs so emerging workload pressure reaches management before sickness becomes the main signal.

Recruitment continues, but retention data now carries equal weight.

The establishment begins monitoring vacancy duration, sickness, turnover, temporary staffing, unfilled shifts and employee feedback together. The workforce problem becomes a quality-and-capacity issue rather than an HR statistic isolated from resident care.

Professional Recognition Needs to Match the Complexity of Modern Care

One of France’s deeper workforce challenges is cultural as well as financial.

Long-term care work has frequently been described through tasks: washing, dressing, preparing meals, cleaning or helping someone move.

That description substantially understates the work.

A skilled aide à domicile may notice early signs of infection, cognitive deterioration, carer exhaustion, medication problems or emerging self-neglect. An aide-soignant in an EHPAD may recognise a change in behaviour that indicates pain or delirium. These professionals often spend more time with the person than senior clinicians do.

Their contribution therefore includes observation, relationship-building, prevention, communication and escalation.

Professional recognition requires these functions to become visible in competency frameworks, training, supervision and career routes.

The professional home-care card introduced from 2025 is one element of that direction because it explicitly identifies qualified workers. The wider question is whether recognition translates into a stronger occupational identity and meaningful progression.

This matters for recruitment among younger workers. A profession that appears to offer limited progression will struggle to compete with sectors where qualifications lead visibly towards more senior or specialist roles.

The future workforce architecture must therefore show how someone can enter the autonomy sector, gain formal qualifications, deepen specialist capability, move into supervision or coordination and potentially progress into other health or social professions.

Recognition is strongest when it creates a career rather than simply giving a more respectful title to the same constrained job.

Training Is Becoming a Strategic Capacity Investment

France is strengthening professional development across the autonomy sector.

In 2026, the CNSA agreed more than €33 million of training support through new arrangements with OPCO Santé and Uniformation. The funding supports diploma-based and professional development routes across establishments, services and the home-care sector.

The strategic importance extends beyond maintaining existing competence.

Training can widen the recruitment pool by allowing workers to gain qualifications while employed. It can support progression, improve retention and prepare staff for increasingly complex needs.

Demand is changing. Workers encounter dementia, end-of-life care, multiple chronic conditions, mental-health needs, disability, assistive technologies and more complex delegated or coordinated care.

This makes workforce training inseparable from service transformation.

However, training creates an operational challenge of its own. A service already short of staff may find it difficult to release employees for learning without creating additional rota gaps. Small home-care organisations may have less administrative capacity to plan qualification pathways than large groups.

Funding therefore needs to address the practical cost of workforce development, not only course fees.

The stronger model protects learning time, links qualifications to progression and measures whether training changes practice.

The Governance Maturity Assessment can help organisations examining comparable workforce questions test whether training, accountability and operational oversight are connected. It is not a French accreditation tool, but its underlying governance principle is relevant: competence should be treated as an organisational capability rather than a collection of certificates.

Territorial Workforce Planning Matters as Much as National Supply

France could increase the total number of trained care professionals and still experience serious shortages if those workers are concentrated in the wrong places.

Recruitment difficulty varies between territories. Rural and isolated communities face different pressures from large metropolitan areas, while overseas territories and islands encounter additional continuity and mobility issues.

Housing costs also influence labour supply. A worker may be able to reach employment geographically but not afford to live close enough to make irregular shifts practical.

Territorial planning therefore has to connect several datasets:

• the current and projected population needing autonomy support;
• existing EHPAD, home-care and intermediate-housing capacity;
• vacancy, turnover and absence rates by profession;
• training capacity and the movement of newly qualified workers;
• travel times and transport infrastructure;
• the use of temporary staff and persistent unfilled capacity.

France’s developing plateformes des métiers de l’autonomie are particularly relevant here.

Launched experimentally from 2021, these territorial platforms bring together employers, employment actors, training organisations and other partners to improve recruitment, professional orientation and retention. CNSA evaluation found sufficient value for the model to move towards wider generalisation, expected by 2027.

The platforms reflect an important change in approach. Employers are not left to solve a structural labour shortage independently. Recruitment becomes a territorial ecosystem issue involving France Travail, training organisations, départements and medico-social employers.

The 2025 cooperation agreement between the CNSA and France Travail reinforces that direction by linking national employment infrastructure more closely with recruitment into the métiers de l’autonomie.

The Digital Twin Scenario Modeller provides a practical framework for organisations considering similar capacity questions. It can help explore how vacancy rates, demand growth and staffing assumptions interact, although it is not part of France’s official workforce-planning infrastructure.

Operational scenario: A département discovers that training more workers is not enough

A département funds additional training places for home-care professionals after employers report severe recruitment difficulty.

Completion rates are encouraging, yet twelve months later services in the most rural communities still report significant vacancies.

Analysis through the territorial workforce partnership shows that many newly qualified workers have taken jobs in the département’s largest urban area. Employment there offers denser travel routes, more full-time opportunities and easier public transport.

The problem is no longer a simple training shortage.

The département examines targeted mobility support, employer cooperation around guaranteed hours, local recruitment pipelines and whether rural routes can be organised across service boundaries more efficiently. Training providers also begin collecting destination data so qualification success is measured not only by course completion but by where graduates actually enter employment.

This produces a more useful workforce indicator: not “how many people did we train?” but “did the training increase sustainable capacity where demand exists?”

That is the level of evidence required if territorial workforce initiatives are to influence future funding decisions.

Temporary Staffing Can Protect Continuity but Also Conceal Structural Weakness

When permanent recruitment does not meet demand, establishments and services need ways to keep operating.

Overtime, short-term contracts, replacement pools and agency staff can all protect immediate continuity. Without them, residents may face delayed care, reduced activity or unsafe staffing pressure.

But prolonged reliance on temporary labour creates different risks.

Financial costs increase. Permanent employees repeatedly orient unfamiliar colleagues. Continuity with residents deteriorates. Temporary workers may know the organisation’s general requirements but not the person’s communication style, routines or subtle early warning signs.

High use can also create a feedback loop. Existing workers experience more unstable teams, increasing dissatisfaction and further weakening retention.

This is why workforce resilience and continuity should be measured alongside vacancy rates.

A service that technically fills every shift through emergency staffing may appear adequately resourced, while its underlying permanent workforce deteriorates.

Organisations therefore need to distinguish between temporary staffing used as a controlled resilience mechanism and temporary staffing that has become the normal operating model.

The same principle applies to repeated overtime. Additional hours can protect care during short disruption, but a rota dependent on permanent exceptional effort is not sustainably staffed.

Workforce Capacity Is a Quality and Safety Measure

Staffing numbers have direct consequences for the experience of older people.

Insufficient capacity may appear through rushed personal care, reduced continuity, fewer opportunities for meaningful interaction, postponed reviews or reliance on hospital transfer because the home or EHPAD team cannot sustain greater complexity.

The important governance question is not simply whether a statutory staffing minimum has been met.

It is whether the available skill mix can meet the needs of the actual population.

Two EHPADs with the same number of residents may require different workforce models if one supports substantially more people with advanced dementia, severe mobility limitations or complex nursing needs.

Similarly, two home-care organisations delivering the same number of funded hours may face very different capacity pressures if one operates in a dense urban neighbourhood and another serves widely dispersed villages.

This connects workforce governance directly with safe staffing and deployment.

Useful assurance should therefore combine inputs and consequences. Vacancy rates matter, but so do missed or delayed home visits, sickness, overtime, agency dependency, continuity, resident outcomes, complaints and preventable service breakdown.

The Quality Dashboard Builder can help organisations structure these relationships between workforce measures and quality outcomes. Used appropriately, a dashboard moves the discussion away from a single staffing number towards a view of whether workforce pressure is beginning to affect care.

Technology Can Improve Productivity but Cannot Replace Relational Care

Digital transformation will influence how much time the future autonomy workforce can spend directly with people.

Scheduling systems can improve home-care route design. Mobile records can reduce repeated documentation. Interoperable information can prevent workers from repeatedly collecting data already held elsewhere. Telecare and remote monitoring can identify changes in risk without requiring unnecessary visits.

These gains matter in a workforce-constrained system.

But productivity should be defined carefully.

Reducing ten minutes of duplicated administration may create valuable time. Reducing a personal-care visit by ten minutes simply because the rota is under pressure is not the same form of efficiency.

Technology can also create additional workload if systems do not communicate, staff are poorly trained or digital documentation is layered on top of existing paper processes.

The future workforce therefore needs digital competence as well as access to technology.

France’s wider autonomy-sector digital transformation creates opportunities for better coordination, but implementation needs to remain grounded in work design. Systems should remove friction and support judgement rather than turn professionals into data-entry operators.

The Digital Transformation Readiness Assessment can help organisations examining similar change test whether technology, workforce capability and operational processes are aligned. The framework is generic rather than France-specific, but the principle is highly relevant to an autonomy system seeking productivity without dehumanising care.

Recruitment Needs to Broaden Without Lowering the Value of the Work

France cannot meet long-term workforce demand solely by competing more aggressively for the same existing pool of experienced workers.

The sector needs new entrants.

That includes younger workers, people changing careers, unemployed people who can be supported into professional qualifications and, where appropriate, internationally recruited workers.

Recruitment therefore needs to challenge the perception that elder care is employment of last resort.

The national Prendresoin initiative launched in 2024 is part of this broader effort to make care, social and support occupations more visible and understandable to potential applicants.

Territorial autonomy-workforce platforms similarly aim to improve orientation into the professions rather than waiting until someone independently applies to a provider.

But expanding recruitment must not become a route to weakening competence standards.

A labour shortage can create pressure to reduce barriers to entry, yet people receiving support increasingly have complex needs. The stronger approach makes entry accessible while providing training, supervised development and qualification routes.

This is where recruitment strategy must connect with professionalisation.

International recruitment may also form part of the response in some professions, particularly nursing, but it raises wider ethical and practical questions: recognition of qualifications, language, integration, housing and the effect of recruitment on countries that have workforce shortages of their own.

Migration can supplement a workforce strategy. It cannot substitute for making domestic employment sustainable.

Operational scenario: Filling vacancies without creating another turnover cycle

A large elder-care organisation needs to recruit dozens of staff across home services and residential establishments. Previous high-volume recruitment campaigns generated applicants, but many left within their first year.

The organisation changes the question from “how quickly can vacancies be filled?” to “what makes a new recruit remain?”

Job previews become more realistic. Candidates understand travel expectations, weekend working and the emotional demands of care before accepting employment. New starters receive structured induction and named support rather than being deployed immediately into the hardest-to-fill shifts.

Managers monitor departures during the first three, six and twelve months and compare them by service, contract type and supervisor.

One location shows consistently poorer retention despite similar pay. Interviews identify unpredictable rota changes and weak day-to-day management rather than dissatisfaction with the profession itself.

The organisation can now intervene at the right level.

The example demonstrates why recruitment and retention cannot be governed separately. A service can report impressive recruitment numbers while losing capacity almost as quickly as it creates it.

National Funding and Local Employment Decisions Must Connect

Workforce ambition cannot be separated from the way long-term care is financed.

An EHPAD or home-care organisation cannot sustainably increase salaries, supervision or staffing merely because recruitment conditions suggest it should. The income available through public funding, tariffs, départemental arrangements, household contributions and other reimbursement mechanisms places boundaries around employment decisions.

This creates one of France’s most important strategic tensions.

Government can encourage employers to improve pay and working conditions while simultaneously requiring the autonomy system to contain expenditure. Yet demographic growth means the system needs both more workers and better employment conditions.

The 2024 bien vieillir law explicitly recognised the connection by requiring recurring multi-year legislation for the grand âge to establish a public-finance trajectory covering ageing at home, institutional care and professional recruitment.

The original timetable for the first programming law was not achieved, illustrating the continuing difficulty of converting broad consensus about demographic need into a settled long-term financial trajectory.

This is important because workforce planning operates over years.

Training capacity cannot be expanded instantly. Career perceptions take time to change. Buildings and home-care service models affect workforce demand decades into the future.

Annual financial decisions therefore need to sit within a longer demographic view.

France’s 2026 projections give policy-makers a clearer workforce horizon. The question is whether funding architecture will respond early enough to build the estimated additional 150,000–200,000 jobs rather than trying to recruit them after demand has already materialised.

Better Workforce Data Should Drive Intervention Earlier

Staffing pressure often becomes visible only after services are already struggling.

A vacancy is a lagging indicator: it shows that a post is empty. More useful governance asks what happened before the vacancy and what happens because of it.

Relevant signals include applications per vacancy, recruitment time, withdrawal rates, probationary turnover, sickness, occupational injury, overtime, agency expenditure, training completion and workforce distribution.

These should then be linked to service evidence.

Are missed home-care interventions increasing? Are EHPAD residents experiencing more staff changes? Are managers spending increasing amounts of time covering shifts rather than leading services? Are waiting times growing in the same territories where vacancy rates are highest?

This is the purpose of stronger workforce data and performance measurement: not to create another reporting burden, but to identify which employment pressure is translating into reduced care capacity.

National bodies can then distinguish between common sector-wide problems and local ones. One territoire may need additional training capacity; another may principally need transport solutions; another may have adequate recruitment but unusually poor retention.

Without this distinction, broad workforce funding risks being distributed without addressing the actual constraint.

The Strategic Shift Is From Filling Jobs to Building a Profession

The direction of French reform increasingly recognises that long-term care cannot be sustained through recruitment activity alone.

Professional cards, pay revaluation, mobility support, occupational-health investment, territorial autonomy-workforce platforms, France Travail cooperation and major training programmes all point towards a broader professionalisation agenda.

The next stage is making these interventions reinforce each other.

A professional card has limited effect if the job remains financially unattractive. Higher pay will not retain someone working in an unsafe environment. Training has limited value if it produces no visible career progression. Digital technology will not improve productivity if employees are not involved in redesigning their work. Recruitment campaigns will repeatedly fail if new starters encounter the same unresolved organisational problems that drove experienced colleagues away.

France therefore needs a workforce compact in practical rather than rhetorical terms: adequate remuneration, manageable work, professional identity, training, progression, supportive management and credible staffing capacity.

That is also the foundation of staff retention.

The demographic case for investment is strong because workforce instability creates costs elsewhere: agency expenditure, repeated recruitment, hospital admissions, exhausted carers and the loss of home-care capacity that policy is simultaneously trying to expand.

International Learning From France’s Workforce Challenge

France’s employment system, collective agreements, départemental responsibilities and Autonomy branch cannot be transplanted directly into other countries.

Several principles are more widely applicable.

First, workforce demand should be modelled alongside demographic and service-model change. A policy to support more people at home is simultaneously a labour-market policy because it changes where, when and how care workers are needed.

Second, pay matters but retention is multi-dimensional. Travel, equipment, supervision, workload, status and career progression can determine whether a salary increase produces lasting workforce improvement.

Third, territorial workforce shortages require territorial responses. National qualification numbers can conceal major geographic mismatch.

Fourth, professionalisation and recruitment are complementary rather than competing objectives. Lowering the perceived status of work may broaden the initial applicant pool but makes long-term retention harder.

Finally, workforce indicators should be treated as quality indicators. Continuity, capacity and competence affect the lived experience of people receiving care long before a service formally becomes unable to operate.

Conclusion

France’s long-term care workforce challenge is often described as a shortage of people, but the deeper issue is the sustainability of the jobs themselves. Population ageing will create substantially more demand for support, while the national shift towards home-based care will require professionals to work with greater autonomy across increasingly complex and geographically dispersed situations.

Recent reforms have created important foundations. Pay has been revalued across major parts of the sector. Home-care work has gained stronger formal recognition. The CNSA is investing in training, occupational health and territorial recruitment infrastructure. Mobility is being treated as a workforce issue, and autonomy-workforce platforms are moving towards wider deployment.

The remaining challenge is integration. France will not create the workforce required for 2050 through isolated recruitment campaigns, qualification programmes or salary measures. Employment conditions, service funding, career development, technology, territorial planning and quality governance must move together.

The central test is practical: can an older person’s assessed need reliably become support delivered by a skilled professional who has enough time, stability and organisational backing to provide good care?

If France can make autonomy work a credible long-term profession rather than a difficult job that continually needs replacing, workforce reform will do more than fill vacancies. It will determine whether national ambitions for ageing at home, better EHPAD care, prevention and personal choice can actually be delivered at the scale demographic change now requires.