Is the French health system (really) picking up?

It seems a long time ago when the French healthcare system was considered the best in the world. Since the World Health Organization (WHO) awarded this first place to France in 2000, the machine has gradually jammed. Twenty years later, in 2021, the Organization for Economic Cooperation and Development (OECD) pointed to the poor performance, particularly in terms of prevention, of the French system. the think tank English “Legatum Institute” ranks France 20th in terms of health systems, far behind Japan, South Korea and Sweden.

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Vocational crisis, difficulty in accessing healthcare… these are some of the symptoms of a health system that is out of breath. The fault, according to caregivers, to more than 40 years of public policies aimed at reducing the supply of care, through, among other things, the numerus clausus. Today, the government is looking for the ideal treatment to heal the wounds… taking inspiration from abroad.

Thursday, January 19, for example, the National Assembly unanimously adopted, at first reading, the bill of the deputy Renaissance Stéphanie Rist “improving access to care through trust in health professionals”. A text that partly imports the Anglo-Saxon model since it provides direct access, without medical prescription, to certain nurses in advanced practice (IPA), masseurs-physiotherapists and speech therapists. If this bill must still be examined by the Senate on February 14, it is in line with the guideline enacted by Emmanuel Macron.

Years behind in task sharing

“We will allow the French to have recourse to other health professionals for prescription renewals for chronic diseases, for vaccination, for screening, for therapeutic education which must be able to be carried out by pharmacists, midwives, nurses and nurses”, promised the President of the Republic during his greetings addressed to caregivers on January 6 at the Corbeil-Essonnes hospital.

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France is particularly behind in this area. And for good reason, the first advanced practice nurses appeared in the 60s and 70s in the United States and Canada. This new profession then spread to certain European countries such as the United Kingdom, where advanced practice nurses have been authorized to perform surgical operations for several years now. In Canada, nurses can even continue their studies in thesis and become doctors of nursing sciences.

In a rapport handed over to the government in November 2021, the General Inspectorate of Social Affairs (Igas) advocates “widening the scope of intervention of nurses in advanced practice by correcting texts prohibiting […] patients to consult an IPA on their own initiative; APNs to first prescribe, to their patients, certain treatments (analgesics, nursing care or rehabilitation, etc.) or services (notice of work stoppage, transport prescriptions, etc.) necessary to support the patients they follow and proper management of their pathology”.

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But the delegation of certain medical acts is faced with “strong opposition”, points out Igas, considering that “advanced nursing practice has no [donc] could not develop to the height of the objectives set”. Many doctors’ unions fear that the general practitioner will lose his status as a “pivot” or conductor in the patient care pathway. “There is no question of allowing direct access to IPAs, nor of granting them first prescription. It’s a profession that it was not necessary to create”, protests Sophie Bauer, president of the union of liberal doctors (SML), considering their training insufficient to ensure medical acts. In France, a nurse in advanced practice followed a two-year training, at a master’s level, complementary to the training of state-certified nurse, awarded after three years of study. The master includes six months of internship, including two in the first year and four in the second year.

Bad student of prevention…

The backwardness of the French system does not stop at this area. The last panorama of the OECD, published in 2021, points above all to the mediocrity of France in terms of prevention. 24% of the population aged 15 and over smoke daily. That is, 4.2 points more than in Spain, 5.2 points more than in Germany, 8.6 points more than in Belgium and even 13.1 points more than in the United States. And France does not shine on alcohol either. It is one of the biggest consumers with 11.4 liters per person in 2021, 2.7 liters more than the average for OECD member countries.

Blame it on inefficient communication according to Dr Franck Clarot, medical imaging specialist and president of the National Federation of Radiologists (FNMR) of Seine-Maritime and Eure: “the lack of prevention is probably our biggest fault. In France, we do a lot of fairly rational communication in fact, but not enough because we don’t talk about people’s cognitive biases, their emotions”, considers the one who has invested in social networks to make users aware of vaccination against Covid. -19 during the health crisis. “It’s an interesting means of communication that deserves to be invested a little more by public institutions,” he suggests.

To strengthen prevention, Franck Clarot first recommends moving “from a health care system to a real health system”, considering that France is much more focused on healing and seeks less to prevent patients from falling ill. “There are plenty of countries that do health education, like Canada. It is sorely lacking in education today. However, it could be integrated into physical education and sports lessons to prevent the risks of smoking and eating disorders, for example”. Which would amount, according to him, “to doing prevention before prevention”. Because the screening strategies currently carried out in France are limited. “We target a particular population to have them undergo scans in order to avoid cancers linked to smoking. However, real prevention must be taken a step forward: not smoking for example”, explains the radiologist doctor.

… but some progress

Things are slowly starting to change in terms of prevention: the Social Security financing law for 2023 opens, for example, the possibility of experimenting, for three years, with systematic and compulsory neonatal screening for sickle cell disease. So far, this anomaly of hemoglobin, responsible for the transport of oxygen in red blood cells, is tracked only in a targeted manner in newborns in mainland France, in particular according to their family origins. The latest Social Security budgets also facilitate prevention in terms of sexual health, with 100% reimbursement, by Health Insurance, of HIV testing, carried out directly in a medical biology laboratory, without a medical prescription. is not necessary. Other sexually transmitted infections (STIs), such as Chlamydia infections, will soon be able to be screened without a prescription and then fully covered by Social Security for those under 26 years of age.

Not equipped enough for MRIs and x-rays

But strengthening prevention also involves being sufficiently equipped with heavy equipment to carry out radiology or magnetic resonance imaging (MRI). “In France, we have approximately 15 MRIs and 18 scanners per million inhabitants. This is the last equipment rate established in 2019-2020. It has improved slightly but we remain well below the OECD average which is around 17 MRIs and 26 scanners per million inhabitants”, points out Franck Clarot, doctor specializing in medical imaging. But the rate of equipment is very heterogeneous among the members of the OECD. Germany and the United States have more than twice as many MRIs as France with 34,470 and 37,990 devices respectively, compared to 16,260 for France.

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Problem, this lack of French equipment is partly responsible for the long waiting times that patients undergo before being able to take their exams. “It delays the diagnosis, regrets Franck Clarot. For cancer, whether you have metastases or not, the treatment is not the same”. However, for suspected cancers, the average waiting time for an MRI is one month in France. “And again, in the Pays-de-la-Loire, you can count two months,” insists the radiologist.

But why is France so poorly equipped? “It’s a failing of our system, says Franck Clarot. In France, it is considered that supply creates demand. So if we reduce the supply, we think there will be less demand, but that’s not true”. A logic similar to that of the numerus clausus which, since its creation in 1971, until 1993, divided by 2.5 the number of students admitted to the second year of medicine, going from around 8,600 to 3,500 future doctors in the French universities.

France among the best students for access to healthcare…

Despite the lack of doctors everywhere in France, the OECD ranks France among the countries that offer the best access to care. 99.9% of the population would be covered by essential services. Far ahead of the United States where only 89% of the population has access to these services. However, when looking at the number of doctors in practice, France has only 3.2 doctors per 1,000 inhabitants, slightly below the OECD average (3.6). Germany has 4.4 doctors per 1,000 inhabitants, Portugal and Austria have 5 and 5.3 per 1,000 patients. “In France, there is access to local laboratories everywhere and everything is taken care of if you have your vital card”, comments Lionel Barrand, president of the union of medical biologists (Biomed).

At the hospital, where caregivers suffer from their working conditions degraded by a lack of human and material resources, the average number of beds is 5.8 per 1,000 inhabitants. This is a hair above the OECD average of 4.4. But well below Germany (7.9) and especially South Korea (12.4) and Japan (12.8).

For what quality of care?

But how does France rank in terms of quality of care? If France is far from being among the worst countries, only 71% of the population say they are satisfied with access to quality health services according to the OECD. Admittedly, this is more than in Italy where barely 61% of the population is satisfied. But France is well ahead of Germany and Belgium, countries whose satisfaction rate is 85% and 92% respectively. It fails especially in terms of the quality of primary care. The OECD indeed points to poor use of certain treatments, such as antibiotics: in 2019, 23.3 daily doses per 1,000 inhabitants were prescribed by doctors in France, compared to only 11.4 in Germany and 15.9 in France. Belgium.

One thing, however, remains undeniable. Health expenditure in France remains mainly covered by Social Security, up to 80% of the consumption of medical care and goods (CSBM), yet estimated at 226.7 billion euros in 2019. medical biology, for example, the average cost in France is 57 euros per person per year, compared to 83 euros in Germany. “Unlike in the United States, it is rare to be completely ruined because you have health costs to pay”, concludes Lionel Barrand. As we can see, even if the French system is today weakened, there are however some signs of hope.