An early bronchiolitis outbreak has put French paediatric hospital services under pressure and forced the government to react with the provision of EUR 150 million in emergency funds, but this crisis is by no means the first for French healthcare. France’s healthcare system, based on a statutory health insurance (SHI) scheme that provides universal coverage, has been in a tight corner for some time. Here are some of the key factors behind the long-standing crisis.
Unfortunately, hospitals have been mistreated for decades.
François Braun, Minister of Health
On October 23, the Minister of Health, François Braun, announced a EUR 150-million plan for “hospital services under tension,” particularly in paediatrics after this year’s early outbreak of bronchiolitis, a common lung infection amongst young children and infants, has pushed emergency paediatric services to the limit of saturation. The plan, known in France as a “white plan,” or an immediate action plan to deal with an exceptional health situation, will recall additional personnel to deal with the wave of bronchiolitis, yet most, including the minister, would agree that the lack of staff is not specific to the current crisis. “This is not new. Unfortunately, hospitals have been mistreated for decades,” he said in a recent interview.
Caregivers have criticized the measure as a mere band-aid on a system that is plagued with inadequate working conditions that have led to an ever-increasing number of paramedical and medical staff vacancies that remain unfilled. “We explain that we want structural, urgent reforms and we are answered with a plan [which] only stretches the way we practice care,” said Mélodie Aubart, neuro pediatrician at the Necker Hospital in Paris.
Reasons behind the staff deficit
Ultimately the prices and not the needs of the patients determine the practice.
André Grimaldi, Professor Emeritus, Pitié Salpêtrière University Hospital
Unfortunately, the staffing shortage at French public hospitals has indeed been a long-standing issue. Although the pandemic overstretched the system even further, the lack of sufficient personnel and complaints among existing staff predate the COVID crisis. Already in 2019, hospital workers were protesting, claiming that the healthcare system was being pushed to the limit, and 70 public hospital directors issued a joint statement, asserting that the system was facing a complete breakdown.
Nurses are particularly in short supply. 1,400 nursing positions in the Paris public hospital system, for example, went unfilled at the end of 2021, according to Le Figaro Santé. The shortage has led to the elimination of a large number of hospital beds and the cancellation of medical procedures considered not urgent. But what is behind the widespread staff shortage?
Low salaries are of course an issue as France ranks surprisingly low with respect to nurse’s salaries among other developed nations. According to data from the World Economic Forum, the country comes in at 28th out of the 32 countries surveyed.
Beyond wages, a lack of motivation has also been pinpointed as the cause for many to abandon the profession. According to a 2021 survey carried out by the Order of Nurses, 40 percent of the nurses consulted wanted to change jobs. Their lack of motivation is based largely on the deterioration of work conditions, with a lack of empowerment and recognition being especially identified.
According to some, the root cause of these worsened conditions is the activity-based pricing system, also known as “T2A”, that became the main funding method for hospitals in 2004. It consists, broadly speaking, in funding hospitals according to the number of treatments they provide. Before that, hospitals had an annual global budget which gave them visibility, but no flexibility in the event of an increase in their activity. The idea behind the T2A was to make the system more flexible, but it quickly had the effect of pushing hospitals towards the logic of profitability.
With this system, “ultimately the prices and not the needs of the patients determine the practice,” according to André Grimaldi, professor emeritus of diabetology at the Pitié Salpêtrière university hospital and co-founder of an inter-hospital collective.
The government plans to pass a new law to reform the system, following measures introduced in 2020 to address the strain caused by Covid, but as of yet nothing definitive has been put in place.
Another negative phenomenon within the French healthcare system is what is known in France as a “medical desert,” or a rural area or small town left without medical services as local GPs retire and are not replaced and small hospitals and clinics close and move services to cities.
This situation has forced patients in less populated areas of France to travel to big cities for treatment and caused emergency services to be overrun with non-emergency patients who cannot find a doctor in their area.
A senatorial report submitted on March 29, 2022 found that 30.2 percent of the French population lives in a medical desert and as many as 1.6 million people forgo healthcare each year as waiting times for appointments get longer. Moreover, the number of practicing GPs has fallen by 1 percent every year since 2017.
To address this situation, French authorities planned a comprehensive reform of community care in 2017 and reinforced this with the 2022 Ma Santé plan to incentivize doctors to move to medical deserts, promote telemedicine and support the development of local multi-professional health centres. As of yet, no figures have been published to demonstrate the results of the plan.