Supporting the dependency of the elderly: territorial issues in metropolitan France.

Summary Dependency of the elderly and the republican motto: what are the links? This thesis examines the professional support of dependency, a subject of public interest, with regard to the republican principles of liberty, equality, from which territorial equity derives, and fraternity, from which solidarity derives. The geographical approach, which is innovative in this field, analyzes the professional offer in metropolitan France in a cross-sectional manner, using quantitative and qualitative methods, and at several territorial levels. The aim is to study the territorialization of support for the elderly, i.e., its apprehension based on spatial realities and related processes. Three axes are retained. First, the major terms of the study, such as ageing or dependence, in addition to key national figures, are illuminated by historical realities and testimonies of actors, in national and local perspectives. An analysis of the current organization of the supply for dependent elderly people is carried out, including home helpers and social workers, home nursing services and private nurses, accommodation facilities for dependent elderly people, as well as coordination structures. The second part of the thesis focuses on the territorial anchoring of the professional offer. It is true that the services studied are local, as shown by their comparison with other types of facilities. However, their presence in the départements is not homogeneous; for example, private nurses are more present in the départements on the Mediterranean coast, while home helps and social workers are more present in the départements of northern France. Between complementarities and substitutions, this research studies the economic, social and political issues arising from a differentiated spatial distribution. In the last part of the thesis, two revealing themes are explored. First, the non-use of the Allocation personnalisée d'autonomie à domicile (personalized autonomy allowance for the home), a solidarity-based dependency compensation benefit granted by the Departmental Councils at the request of the individual, is studied. Next, the determinants of migration of people when they enter an EHPAD. The difficulty lies in the fact that the same behaviors, of non-use or migration, can reflect both the choices of individuals and the failure of the public authorities to provide an adapted and available offer in the territories. An analysis of individual determinants, based on detailed databases and on the testimonies of local actors, makes it possible to distinguish the limit between individual freedom and the responsibility of public authorities. This study produces territorial diagnoses, potential decision-making tools, for DREES, which is the funder, and the four partner departmental councils.