Introduction: Despite continuing efforts by national and local policy-makers, the French health and social care system still remains fragmented, often resulting in many problems for the users, their family, as well as the local managers and providers of care (Bloch, 2013; Bloch and Hénaut, 2014). Most of the recent attempts to overcome fragmentation regarding elderly care took the form of pilot projects. In this paper, based on literature and ethnographic materials, we argue that integration has been difficult to achieve because pilots have been launched, at the national level, by siloed and competing administrations, and circumscribed, on sites, to either health or social care providers. However, new trends in policy piloting seem to be able to change the course of that story. First, some pilot project managers have been able to work with local managers and care providers in order to achieve what we call “integrative piloting”. Second, the rise of a social movement among integrated care pilot project managers is impacting the development of integrated care policies both at the local and national levels.Methods: The paper is based on literature and ethnographic materials. First, complementing the work of Somme and de Stampa (2011), we traced the history of coordination and integration policies for the elderly in France thanks to a systematic literature review of more than 300 documents produced by scholars or policy-makers. Second, we conducted an in-depth analysis of three major coordination schemes that have been implemented across the country after several years of piloting: _CLIC, Réseaux_ and _MAIA_. Interviews and observations have been done in four sites (center of Paris, North East suburb of Paris, Marseille, Ile de la Reunion). Interviews focused on the work of pilot project managers and front-line professionals involved in coordination schemes (N=45), local policy makers (N=15), and leaders of newly created associations or networks related to the different pilots (N=4). Finally, we attended assemblies and training sessions arranged for the managers of the three coordination schemes.Results: At the level of national policy-makers, each administration (social affairs, health care, long term care, and social security) tried to overcome fragmentation by developing its own coordination scheme. The lack of interaction and the on-going competition between administrations, along with the inability to conduct or use public policy evaluations, resulted at the local level in a never-ending struggle against fragmentation. The paper presents the complex web of competing and overlapping coordination schemes in the settings that have been investigated.While most professionals had a limited view of health and social care providers for dependent elderly persons, and of coordination schemes, some project managers succeeded in developing local integration by implementing what we call “integrative piloting”. They got other managers and providers on board thanks to the display of relational and entrepreneurial skills. They also took advantage of calls for applications offered by different administrations to channel new funds and build innovative collaborative schemes.In addition, our study shows the increasing role of the newly created associations and networks of the project managers who are piloting and managing coordination schemes in the development of best practice guides. They are in the process of combining their efforts in order to attract the attention of national policy-makers on several “local success stories”.Discussion: Centrifugal forces take place both at the national and local levels. Because of the lack of learning process, policy-makers have been creating layers of coordination schemes. However, in-depth case studies reveal that it is possible to redesign the different pilots depending on the local context and convert the layers into integrative schemes. The role of the newly created associations of project managers as part of a new centripetal force can be discussed.Conclusion: There is no doubt that national administrations should intervene in a more coordinated way. Moreover, on the face of it, the management of the complexity of the health and social care system can also benefit from local initiatives, and from meso-level organizations such as the association of networks of coordination schemes managers. Only time will tell if these new trends will become perennial.
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May 6, 2024
Olga Vasovic 
Open Access