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Healthcare at a Territorial Level: a French Imperative

Healthcare at a Territorial Level: a French Imperative
 Laure Millet
Fellow - Healthcare
 Emma Ros
Policy Officer - Healthcare Policy Program

The French healthcare system is facing numerous challenges, which include a COVID backlog, quitting in droves, an aging population, chronic illnesses, the current crisis in emergency services… Against this backdrop, the perception of the public hospital is strongly degrading and patients fear they will be less well cared for. A few numbers reflect this reality: 74% of French estimate that the healthcare system has decayed over the last few years, and 37% feel they live in a medically underserved area. Moreover, healthcare practitioners themselves are struggling: statistics attest to widespread exhaustion, with 50% of healthcare practitioners reporting they experienced burnout, and 63% very often subject to one of the many symptoms of work-related exhaustion. In May 2022, 90% of healthcare practitioners agreed the healthcare system had deteriorated over the past few years. In this context, retaining the workforce is proving increasingly difficult. The structure of the healthcare system holds partial blame for the emergence of this current crisis, as does its governance: the absence of pluriannual budgets or the non-articulation of a coherent national preventative strategy are pressing issues. 

A healthcare system grounded in solidarity is an essential component of the French social contract. The stakes are high when it comes to ensuring current crises are addressed sustainably. We acknowledge and applaud the reactivity of local actors during the pandemic, both public and private, and we commend the recent national impulse towards a less top-down approach to governance. Nevertheless, Institut Montaigne believes more can be done to facilitate the way the French healthcare system works. Our policy brief published in May 2022 "Santé: faire le pari des territoires" ("Healthcare: let’s bet on local actors") articulates three important proposals: giving local actors the necessary tools for them to act autonomously, supporting the local level as a key force behind healthcare policies, and making effective public health a national concern.

Giving local actors the necessary tools for them to act autonomously

One of the most important steps to transform the French healthcare system is enabling its actors to act freely and autonomously, independent from the burden of administrative procedures. To do so, education of healthcare workers, both at the start and through-out their careers, is an important vector of transformation. Currently, medical education in France does not place sufficient emphasis on the value of collaboration and cooperation between actors of the health system. To remedy this, training in multidisciplinary and integrated units should be made mainstreamed. Such experiences enable actors across the field to adopt a global approach to health, which allows for methods of care that account for both a patient’s psycho-social background, and his/her clinical and biological profile. Interestingly, it is also worth noting that France is one of the only countries in the European Union where hospital directors must sit an entrance exam and train as a civil servant. In many other countries, hospital directors can come from the private sector. Shifting towards a more collaborative and innovative training for all healthcare actors would benefit cooperation. 

Shifting towards a more collaborative and innovative training for all healthcare actors would benefit cooperation.

Additionally, Institut Montaigne stresses pursuing investments that restructure the current system. Countries like the UK have been at the forefront of highlighting the importance of primary health care through large healthcare reforms i.e. the Health and Social Care Act of 2012. This brought the biggest changes to the National Health Service since its creation in 1948, which emphasized the necessity to develop community and integrated models of care, as well as the potential of leverage on digital health and data tools.

In Germany, Medizinische Versogungzentren (MZV) are good examples of pluridisciplinary spaces of collaboration in the medical field, as they ask for at least two medical specialities to co-exist within the same space, all whilst promoting mixed status modes (a doctor can work both there and in the hospital). When it comes to France, it is necessary to continue investing more money in what is called médecine de ville ("city-care"), which encompasses GPs and specialized medicine in private clinics, as well as community health centers, known as maisons de santé. In 2018, the government suggested actors within the same area could coordinate to tackle specific health issues through groupings called Communautés professionnelles territoriales de santé ("Health professional territorial communities"): this was an opportunity to clearly articulate collaboration between health professionals within a local area. Other opportunities to transform primary care includes conferring GPs a public health mandate, or enabling pharmacists and nurses to complete more tasksthan they have previously been allowed. Essentially, the idea is to make the current health system structure, highly constrained by its silos, evolve.

Supporting the local level as a key force behind healthcare policies

Regained autonomy and freedom for healthcare actors also means increased responsibility at the local level. In 2007 in Denmark, a large structural reform was initiated, reducing the number of municipalities from 271 to 98, and the number of regions from 14 to 5. This led to a new division of tasks between states, regions and municipalities, as well as the implementation of a new financing system which made regions responsible for handling the health budget along with municipalities. In France, despite some legislative restructuring and reshuffling (which started as early as 2009) with the Hospital, Patients, Health, Territories law, which implemented "Agences Régionales de Santé'' (Regional Health Agencies) and "Groupements de coopération sanitaire" (Health Cooperation Groupments), transformation of the health system is far from being fully implemented. Now is the time to push this impulse further, notably by further involving politics in the governance of their local health systems, and vice-versa. 

To truly own up to their new missions, it is essential for the local level to be supported both financially and materially. For this to be done adequately, they must also be able to identify their own populations’ health needs. Inspired by the highly digitized and data-driven Nordic health system, it is due time for France to implement a data-driven steering of the healthcare system tailored to the local level. This is the case of Norway, for example, which relies on the Norwegian statistics agency "Statistics Norway" to record data at a local level (health-related amongst others: patient statistics, municipal services…).

To truly own up to their new missions, it is essential for the local level to be supported both financially and materially.

This enables the healthcare system for smarter and more adequate handling. Institut Montaigne produced in association with start-up Kanopy Med a mapping of health needs and resources available in France, with the objective of highlighting departmental disparities in the allocation of health resources. This map additionally demonstrates that population health needs vary from regions to regions. For instance, populations from departments termed "bien portants" (healthy) showcase low levels of chronic diseases relative to the national mean. These observations are a starting-point for policy makers to reflect on different department's management of health expenditures. 

In this sense, the French system must better evaluate the effectiveness of innovation within the healthcare sector to promote evidence-based changes to current practices. If some fear such an approach might lead to a solely cost-effective approach to healthcare, it might be wiser, rather, to see it as an opportunity to further value patient-experience and voices, actively taking care of what researchers term "démocratie sanitaire" (health democracy - meaning the involvement of all individuals in the process). Typically, this can translate to implementing citizen health assemblies at the local level, as well as developing new tools to record patient experience. Recording patient experience is much less systemic in France than it is abroad in countries like the Netherlands, where for example, the Dutch Surgical Colorectal Audit, put in place in 2009, is used by all hospitals. 

Making public health a national concern

In the wake of a pandemic which has revealed how health can constitute a pillar for a country's stability, rethinking our French health system is also an opportunity to articulate a larger societal project: one which states public health as a key national objective. This is a tendency carried by world organizations like the WHO, which implemented in 2020 a Council on the Economics for All, aimed at attracting investment in healthcare, but also explicits how a healthy society also creates value in itself (i.e. value creation and economic growth). A similar line of thought is encompassed by the buzzword "One Health", which emerged in the 2000s. In light of current crises (climate, democratic), this approach is particularly meaningful: our health is dependent on that of our environment, and a healthy population is a key element of a functional democracy. Concretely, one way to implement it tangibly is by applying the concept of population-based responsibility. Born in Canada, this approach aims to make all health actors (public, private, medical, social) responsible for maintaining their population in a healthy state. Trials for implementation in 5 French regions are currently in place. 

We have thus seen how the local level is paramount to better managing citizens’ health. Yet public health knows no borders. A European response to current health threats will also be necessary in the years to come. Coordinated responses to the pandemic have highlighted what can be gained from collaboration, future projects are now in our hands. The current development of the European Health Data Space holds significant potential for both patient experience and future research. Institut Montaigne also believes our respective care systems have much to learn from one another. Last but not least, it cannot be forgotten: ensuring that citizen health sits at the crossroads of other geopolitical issues, whether building sovereignty in the pharma field, or safeguarding cybersecurity in general. 


Co-written with Laure Mourgue d’Algue, Assistant Policy Officer.


Copyright: Aris Oikonomou / AFP

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