The Vice President of Health and Medicine at Pierre and Marie Curie University (UPMC) and Director of the University’s Institute of Oncology reveals how the French social security system needs to look at how to evaluate real needs, why the patient has to become more involved in the decisionmaking process, building a health democracy, and how France's 35-hour week has had a damaging impact when it comes to the country´s healthcare system.

How would you characterize France´s social security system as it stands today?

Our system of social security is at a turning point and its financing is very much in question. For the last 70 years, the French system has been based on the concept where people pay what they can and in return they receive what they need, a legacy of General Charles De Gaulle. Increasingly, French people feel that this principle is being questioned. Our social security system of the 1960s looks very different to the one we have today. People’s needs have increased as better treatment results in the fact that we are now all living longer. As people’s average life expectancy increases, but the length of time with which we pay into the system has not shifted, this inevitably creates difficulties.

Moreover, the older you are, the more you cost the system. It was once thought that better preventative treatments and screening capabilities would help to solve some of our financial difficulties. This has not been proven correct. In reality screenings and preventative treatments are expensive and do not change the fact that as you get old, you will eventually develop an illness. Our system has reached a decisive stage with regards to its future financing. Our social security system relies heavily on borrowing, meaning we pay increasing interest. We are living longer and longer, paying for today’s care with money that we will only have in the next five to ten years.

What can be done to put the system back on a stable footing?

There are numerous ways with which we can respond. One could be that everyone contributes what they can and in turn receives what they need; another principle could be everyone contributes what they can and receives what the state can afford. This would imply a fundamental change to our system of redistribution based on solidarity. Such solidarity has its limits. I believe that the choices you make in life are more important than your financial means. You can choose a generic product over an innovative one. We could elect political leaders that are ready to fundamentally redistribute wealth in our society. Yet we see that the electorate is not ready for such a shift. Our system is not challenged when it comes to means, but it is challenged on how to distribute and evaluate real needs. Our system as it stands today has failed to evaluate people´s genuine needs and make real choices. When making choices, they are numerous actors. There is the patient, who has to become more involved in the decision making process, what we call health democracy. At the Faculty of Medicine at Pierre and Marie Curie University, we have created a degree in health democracy. Education of medics is also key, in particular so that they are able to think critically, allowing them to analyse real needs.

What has been the impact of France’s 35-hour week on the healthcare system?

France’s 35-hour week has had a damaging impact when it comes to France’s healthcare system. Martin Hirsch, Director of AP-HP, the public hospital system of the city of Paris, is in the process of renegotiation the length of time one works. We need to look to reduce our spending, while redistributing and modernizing our social security system. Ambulatory care, also known as outpatient care, will also have an important role to play in making indirect savings.

You have said publicly that hospitals must restore their links with the universities. Can you tell us why you believe this is so important?

I created and direct the Institute of Oncology at Pierre and Marie Curie University. I have participated in the expansion of university training areas, particularly by bringing the education of allied health professionals within the university. The objective was to bring together stakeholders active in healthcare, research, teaching as well as the private sector.  Six candidates have obtained the status of being labelled an IHU (University Hospital Institute): three in Paris, one in Strasbourg, one in Marseille and one in Bordeaux. IHUs have on the whole proven to be a great success, providing excellent scientific research and healthcare services. Such a system is not an economic model, but an academic model, building relationships between hospitals and the private sector.

What are the main challenges when it comes to increasing collaboration between different stakeholders in France?

An issue that we have in France, is that expenses are paid by numerous different actors. When the state attempts to save money, the hospital is still expected to treat the patient to the same standard and so loses out.  This leads to diverging interests, and even opposing interests, which we need to look to harmonize. France must retain the same goal of treating every patient according to their needs and make them pay according to their means. We should never change this objective. What we need to do is define these two terms in a more precise manner.

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