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David Kerr: The French Connection—one solution to social care?

2 Apr, 12 | by BMJ

David KerrOld age is not so bad when you consider the alternative wrote the French actor and singer, Maurice Chevalier. In the UK this week, the government announced a forthcoming White paper on social care will be published in June detailing a new system for looking after the elderly in care homes and through improved home help services ensuring that pensioners are no longer forced to sell their homes to cover the cost of care in old age. Last year the Dilnot Commission reported on this subject recommending capping individuals’ lifetime contributions to their social care costs at £35,000, as well as increasing the means tested threshold above which people must fund the full cost of their care from £23,250 to £100,000. However, the costs of food and accommodation in a care home would not be covered.

Across the channel, one unusual approach to preparing for old age is becoming increasingly popular. This is particularly relevant given that France now has one of the highest life expectancies in the world. Under a medieval system known as “viager,” elderly people are encouraged to remain in the own dwelling but can benefit from being paid to live there. Buying a property “en viager” involves making a one-off payment (known as a “bouquet”) and then paying an indexed-linked “rent” to the current occupant until they die. When the owner finally slips his or her mortal coil, the property is transferred to the buyer. The viager system is especially popular for older people without children or those who have lost touch or fallen out with their relatives and would otherwise struggle with a pension as their only source of income.

The elderly property owners—known as “tetes” (heads) advertise their property with details of their ages, the bouquet, and the expected rent. Unsurprisingly, medical details are not released! The viager system may appear to be a sensible investment where both parties do well out of the arrangement, although events do not always run their anticipated course.

In 1965, 47 year old lawyer named André-François Raffray, signed a viager agreement to acquire an apartment in the centre of Arles. The monthly rent paid to the occupant was agreed at 2,500 francs per month and the owner was 90 year old Madame Calment, who smoked, and enjoyed the odd glass of wine. What the Monsieur Raffray didn’t know was that she also rode a bicycle, roller-skated, and had recently taken up fencing. Thirty years later, the lawyer died, leaving his widow to continue making payments to Madame Calment, who was now 120 years old. She lived for another two years, by which time she had moved to a nursing home and eventually became the oldest person ever, surviving 122 years and 164 days. Monsieur Raffray ended up paying almost $200,000 which was more than double the apartment’s value!

Viagers have to live for at least 20 days after they sign the agreements, but unexpected deaths amongst this group of otherwise healthy elderly are unusual. In essence viager is high stakes gambling on an individual’s longevity and the practice is banned in neighboring Switzerland presumably because of a perceived risk of encouraging foul play. It is also said that occasionally sellers feign illness and disability to increase sale prices. Nevertheless the viager system is increasingly popular in France and despite the macabre overtones, is encouraged by the French government as an effective way to reduce dependence on social security programmes.

In the spirit of entente cordiale, perhaps we should think about introducing a similar system here in the UK as it could theoretically result in more elderly people remaining independent for longer in their own homes.

In some ways the French do appear to have a different approach to advancing years than us, summed up again by Maurice Chevalier—“French are true romantics, they feel the only difference between a man of forty and one of seventy is thirty years of experience.”

David Kerr wears many hats, sometimes at the same time—diabetologist, editor of Diabetes Digest, researcher, and founder of VoyageMD.com, a free service for travellers with diabetes and Mylyfe.me a service for women surviving breast cancer. He also believes that social media has the potential to be of huge benefit in improving medical care and practice. He also holds a small amount of stock in CellNovo (a new insulin pump company) and Axon Telehealth.

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