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What Are the Challenges Ahead for the French Healthcare System?

What Are the Challenges Ahead for the French Healthcare System?
 Laure Millet
Fellow - Healthcare
 Emma Ros
Policy Officer - Healthcare Policy Program

In 2000, France’s healthcare system was ranked number one in the world by the World Health Organization. And yet, more than 20 years later, France’s renowned system is grappling with one crisis after another, each seemingly more severe than the previous one. The challenges faced by the French healthcare system are taking place at a time when demand for healthcare services is on the rise. The French population is getting increasingly older. Studies show that in 2050, people aged 75 and over will represent 16% of the population, and that 20% of them will have three chronic diseases or treatments. Warning signs are everywhere that the healthcare system is struggling to adapt to the surging demand for services.

For the past 15 years, emergency wards have been overwhelmed by patients all too frequently, with over 20 million visits per year (compared to only 7 million visits in 1990). In 2019, emergency professionals went on a prolonged strike lasting six months to protest against the overload of emergency services, poor working conditions, and low pay. The COVID-19 pandemic worsened an already fragile situation, bringing more attention to the existing problems within France’s emergency services. This alarming observation was shared in a report from the Senate inquiry commission on the state of hospitals in France, which found that the condition of the hospital system in the country has been deteriorating for several years. In fact, 50% of healthcare workers have reported being victims of burnout and 63% admit to experiencing at least one symptom related to professional exhaustion. The strain on emergency services led to a mass exodus of healthcare workers who resigned from their positions, causing a shortage of qualified professionals. Several emergency units are closed across the country. At the height of the crisis in the summer of 2022, nearly 120 emergency rooms (20% of the country’s capacity) were forced to partially or fully close due to lack of personnel.

The ongoing crisis in emergency services is just one symptom of a more widespread crisis affecting the entire French healthcare system, including outpatient care. Private practitioners organized a strike in December to protest against the difficult working conditions and significant workload they are facing, especially in regions that suffer from a shortage of medical professionals, known as medical deserts. Growing dissatisfaction among healthcare workers compelled unions to call for an increase in the consultation fee from €25 to €50, for private practitioners. However, tensions escalated when contractual negotiations between private practitioners and the national health insurance system fell through. Negotiations occur every five years between the government and medical unions of private practitioners to set the reimbursement rates for medical services.

But France is not alone in its struggles. Healthcare systems are under stress across Europe and face similar challenges. Echoing the strikes in France, the United Kingdom experienced its largest strike in history in February when tens of thousands of ambulance workers and nurses took to the streets to demand a wage increase. The country’s National Health Service (NHS), much like hospitals in France, experienced a significant deterioration during the pandemic, leading to a sharp rise in staff resignations. The United Kingdom is also facing a shortage of caregivers. The situation has become so dire that more than 7 million people were waiting for medical treatment or surgery by the end of 2022. Estimates show that the country has a shortage of 12,000 doctors and 50,000 nurses. The same goes in Germany where 35,000 positions are currently unfilled in the medical sector. And in Spain, general practitioners have been on strike in Madrid since November to demand more resources and an increase in staffing. On February 12, 2023, nearly one million people marched through the streets of the Spanish capital to demand that the government put more resources into the public health system, which has been overburdened since COVID.

As the French healthcare system continues to face crisis after crisis, patients in France are expressing concerns about the quality of care they are receiving. According to recent polling, 74% of the population believes that the quality of the healthcare system has deteriorated in recent years. And 90% of health care providers share this view. In January 2023, French President Emmanuel Macron announced several possible solutions to get the health system out of the "endless crisis" it has fallen into. After the consultations with health system stakeholders in 2020 ("Ségur de la Santé") in the wake of the first wave of COVID-19, which resulted in higher pay for healthcare professionals, Mr. Macron also promised to overhaul hospital care. In addition, the president emphasized the need to reduce administrative tasks that take away from the time medical professionals can spend with patients, in both hospitals and outpatient settings. Access to care, over-reliance on hospitals, and lack of focus on preventive care - the challenges that the French government must overcome are colossal and require major changes in the organization and delivery of healthcare in the country.

The issue of "medical deserts" : an increasing difficulty in accessing healthcare

Access to healthcare is a central concern for people across the country. More than a third of the population (37%) considers that they live in a medical desert.

The issue of medical deserts has gradually worsened in France over the past decade. Medical deserts refer to geographical areas where there is a shortage or absence of medical professionals, making it difficult for residents to get care. People who live in these areas must often wait for long periods of time to see a general practitioner or a specialist, which can lead to major disruptions in patient care. Medical deserts also place a burden on hospitals since patients are forced to turn to emergency care, thereby increasing overcrowding. According to estimates, about 30% of the French population lives in a medical desert. A large portion of the population is having difficulty finding a general practitioner. About 11% of people aged 17 and over, representing more than 6 million French people, do not have a primary care physician, a doctor responsible for coordinating the patient's care pathway (versus 7.6% in 2012). The difficulties in finding healthcare providers are due to a significant decline in the number of general practitioners in France. In 2020, there were 86,000, down from over 94,000 ten years earlier. The shortage of general practitioners is likely to get even worse in the next few years given that more than a quarter of the current workforce is 60 years of age or older and approaching retirement. In addition, the distribution of healthcare professionals across the country remains highly uneven. While the average number of general practitioners per 100,000 inhabitants is 149, there are significant disparities between regions. For example, in the Eure department in Normandy, there are only 100 general practitioners per 100,000 inhabitants, while in Paris, there are 236. Access to specialists is also difficult. Although the national average of specialist physicians per 100,000 inhabitants in France is 188, geographical disparities also exist. There are 12 French departments where the number drops below 100, while in Paris, the number is as high as 635. The issue of medical deserts is a problem that affects many other European countries as well. The density of doctors in rural areas remains low in countries like Germany, Austria, and Switzerland. Furthermore, this issue is expected to worsen due to an aging medical workforce. In Germany, for instance, over 55% of doctors are 55 years of age or older.

In response to the challenges of accessing healthcare and the issue of medical deserts, the French government has implemented several measures. First, to free up time for physicians, the government has launched a series of measures aimed at delegating certain tasks traditionally performed by physicians to other healthcare professionals. In 2021, the Rist Act broadened the competencies of several medical professions, including midwives, physiotherapists, and pharmacists, by expanding their ability to prescribe care and medications. The law also created the concept of advanced practice, which empowers paramedical staff, including nurses, to perform certain tasks that were traditionally reserved for doctors in integrated healthcare systems. In addition, since last November, pharmacists are authorized to administer mandatory vaccinations. Similar measures have been taken abroad. In the United Kingdom, certain NHS nurses are licensed to make diagnoses and establish care plans. In Sweden, some primary care nurses are responsible for seeing patients, assessing their care needs, and are qualified to prescribe specific medications.

To restore the appeal of outpatient care as a profession, the French government is encouraging the development of group practices. These facilities, such as full-service medical centers ("Maisons de santé pluriprofessionnelles") and local practitioner networks ("Communautés professionnelles territoriales de santé"), strive to counteract the isolation experienced by healthcare professionals and enhance coordination among them. The number of these facilities doubled between 2017 and 2022. By the end of 2022, France had more than 2,200 medical centers and nearly 400 local practitioner networks. Currently, close to 400 additional local practitioner networks are being established, the goal being to have 1,000 of them across the country within the next few years.

Lastly, the government is encouraging the use of digital technology in healthcare (specifically telemedicine) to improve access to care. Telemedicine tools make it possible for patients to seek medical advice from healthcare providers located far away from home. Since the pandemic, there has been a surge in the adoption of digital technology in healthcare, particularly in telemedicine. As a result, the number of teleconsultations increased dramatically, with 75% of doctors using this tool during the pandemic (compared to less than 5% prior to 2020). This trend has since become widespread in practice, with over 9 million teleconsultations conducted in 2021. Legislation has also been relaxed to encourage and facilitate the adoption of telemedicine. Tele-expertise has been covered by the French national health insurance system since 2022, allowing healthcare professionals to seek the opinion of a more experienced colleague on a specific matter through remote communication. For medical deserts, tele-expertise is a particularly promising solution, as it allows patients across the country to benefit from the specialized knowledge of expert physicians. Since the beginning of the year, telemonitoring, which allows healthcare professionals to remotely monitor their patients, has become legal.

A system limited by its centralization and its hospital-centered organization

The changing healthcare needs of the French population, including an aging demographic and the increasing prevalence of chronic diseases, have substantially disrupted the existing organizational structure of the healthcare system, which has traditionally focused on hospitals and acute care. Over the past twenty years, France has made efforts to shift away from this approach to develop alternative care models that prioritize outpatient care and long-term care. In spite of these efforts, the average length of stay in French hospitals remains very high, at 8.8 days compared to an average of 7.6 days for OECD countries and 5 days in the Netherlands.

The challenge France faces in reforming its healthcare system lies in effectively deploying care pathways that integrate hospital care, outpatient care, and long-term home care. These new care pathways require greater coordination among healthcare providers. But because they are often located far away from one another, effective collaboration and communication can be more challenging. Several measures need to be taken in order to facilitate this coordination. Digital tools allow for more streamlined information exchanges between healthcare providers. However, there is currently no shared software platform for healthcare providers in France. In January 2022, the French government launched Mon Espace Santé, a digital health record for French citizens that aims to consolidate all health-related documents in one centralized location. The idea is for healthcare providers to have access to this workspace in order to view the health history of their patients. In addition, to improve coordination among healthcare professionals, secure and interoperable messaging platforms are being implemented to facilitate seamless communication between hospital-based, outpatient, and long-term care professionals. However, at present, these tools are still relatively ineffective. For example, Mon Espace Santé remains underutilized by both patients (only 7.9 million patients have created their profile out of 65.7 million insured) and healthcare professionals.

The manner in which professionals are trained in the healthcare sector can also explain the hospital-centric approach of the health system. The training of healthcare professionals is heavily focused on hospitals and is not well-suited to the needs and challenges of outpatient care. Internships are predominantly carried out at healthcare institutions. Furthermore, healthcare professionals are not trained in the essential skills of management and collaboration. According to a report published in 2020, practitioners who hold managerial responsibilities reported that they were not provided with the necessary training in management. Developing the managerial capabilities of healthcare professionals is essential to foster greater collaboration among all stakeholders.   

Additionally, the French healthcare system is based on a fee-for-service model, where healthcare institutions are compensated according to the number of procedures and services provided. A funding model such as this does not incentivize coordination among actors since the time during which providers do not render services is not compensated. This includes time spent organizing coordination among healthcare professionals and the time spent by caregivers working in teams. To address this problem, Mr. Macron announced in January a plan to shift the funding model away from fee-for-service. Several options are being considered, such as a hybrid model that takes into account public health objectives in addition to the procedures and services provided. Some countries, like the United Kingdom and the Netherlands, have opted for a capitation model. Here, providers are paid a fixed amount of money per patient, regardless of the amount of care or services provided. And in the Netherlands, home care is based on the Buurtzorg model where caregivers are paid by the hour rather than by the type of service provided.

Lastly, the French healthcare system is mostly managed at the national level, primarily by the Ministry of Health and Prevention and the statutory health insurance program. Funding for the public health insurance system is determined annually through a specific financing law that establishes the spending target for the year. At the regional level, the Regional Health Agencies (ARS) are responsible for funding and organizing the social and medico-social services within their respective territories. And at the departmental level, ARS delegates are tasked with identifying local needs. However, the current organization of the healthcare system is not flexible enough to adapt to the specific healthcare needs of the population. Institut Montaigne published a map that illustrates the inadequacy between healthcare spending allocated per capita and the actual healthcare needs of the population. Healthcare needs vary greatly from one department to the next, yet the provision of healthcare services is often standardized or insufficiently tailored to meet the specific needs of the local population.

In this respect, it seems necessary to enhance the engagement and participation of local stakeholders in the healthcare system. They are, after all, in the best position to assess the health needs of their territory. In 2022, the French government introduced a law aimed at strengthening the role local authorities play in shaping regional health policies. But rethinking the French healthcare system as a whole requires a greater level of engagement from healthcare professionals and patients alike. To better involve them, some countries, like Canada, have adopted the population health approach. Under this model, all healthcare actors in a given region are required to uphold and enhance the health, well-being, and autonomy of the population. The role of local actors becomes greatly enhanced, as they are tasked with defining healthcare strategies tailored to the needs of their population.

A healthcare system that is more focused on curative treatment over preventive policies

The French healthcare system has historically prioritized treatment over prevention. Indeed, the funding model for the French healthcare system, mainly based on fee-for-service, does not incentivize prevention, as those services may not be covered (or not well covered) by the national health insurance system. The Social Security budget, which is voted on by the Parliament and formulated with yearly objectives, does not offer a multi-year outlook, which is nonetheless crucial for launching a comprehensive prevention policy.

The absence of an ambitious preventive policy has led to a high prevalence of risk factors in the population. In France, the percentage of daily smokers among those aged 25 years and over is 25.5%, a figure twice as high as in the United States and Sweden. Alcohol consumption is also a major concern in France, with an average consumption of 11.4 liters per year, far exceeding the national health insurance system’s target of 4.8 liters per year.

The French population participates much less than other countries in screening and prevention programs. Cancer screening rates, for example, are lower in France than in other countries. Only 22% of eligible women have been screened for cervical cancer, well below the European average of 50%. Similarly, the screening rate for colon cancer is just 34% compared to 50% in the United Kingdom. The story is similar for vaccination programs. France has one of the lowest rates of vaccination against human papillomavirus (HPV) among OECD countries, at around 30% compared to 86% in the United Kingdom, 73% in Spain, and 76% in Denmark. In February, Mr. Macron announced the launch of a generalized campaign to vaccinate children between the ages of 11 and 15 against HPV.

In May of last year, the Ministry of Health became the Ministry of Health and Prevention, an important signal from the government that it now intends to prioritize prevention. It should therefore come as no surprise that the Social Security Budget Act for 2023 introduced new measures for preventive health policies. In particular, it provides for preventive check-ups, or physicals, at three key stages of life: 20-25, 40-45, and 60-65 years of age. The purpose of these consultations is to assess the patient's health condition and prevent the emergence of pathological risk factors. Check-ups are tailored according to the age of the patient. In the current context, it seems difficult for healthcare professionals to take on the brunt of these consultations. In this regard, Institut Montaigne advocates for a comprehensive preventive policy. As mentioned earlier, general practitioners are already overwhelmed with work, and many patients struggle to schedule appointments with them. In order to conduct these check-ups, delegating some of the tasks to advanced practice nurses, medical assistants, or other healthcare professionals such as pharmacists or physiotherapists, could be viable options.  

Co-authored with Manon Palies, Assistant Policy Officer - Healthcare Program


Copright Image: Geoffroy Van der Hasselt / AFP


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