Science and Health

Long waiting times in emergency rooms, overwhelmed GPs, unreachable specialists… Are the French condemned to having ever more difficulty receiving proper care when they are sick, and to seeing the quality of care deteriorate? Cardiologist Olivier Milleron, spearhead of the Inter-hospital Collective, refuses to give up. With Professor André Grimaldi, he published on August 28 a “Guide to misinformation about our health system” (1): the two doctors detail the long list of political errors that have led to the current situation. They also propose reforms, validated by scientific studies and foreign experiences, to remedy this – as well as the savings that would allow them to be financed. Interview.

L’Express: Was the summer easier or more difficult than previous years in hospitals?

Olivier Milleron : In the Paris region, more beds and staff were kept open than usual due to the Olympic Games. At the same time, emergency room attendance was lower than expected. So there were no major difficulties this year. But that should not mask the tensions in the rest of the country, with emergency services still suffering in many establishments. We saw it in Brest, with this “wall of shame” where caregivers displayed the hours spent on stretchers by patients. Other movements are starting, in Aix-en-Provence, Laval, Nantes… The Inter-hospital Collective is organizing a review of the local press and we very regularly see emergency services closed punctually, or for the night, or for which you have to call before showing up.

READ ALSO: The hospital in crisis: the “patient-stretcher”, new gauge of a deep evil, by Professor Pialoux

We can anticipate a worsening of the situation in the coming months, since this year, 1,500 interns will be missing. Faced with a new reform of the national ranking exams, they preferred to repeat rather than risk a bad ranking. They did not trust the new evaluation method! However, interns participate in the on-call care at the hospital. In many establishments, the on-call lists will therefore be even more difficult to fill than usual…

Several reforms have been implemented in recent years to address the difficulties of emergency services – access to care service, revaluation of on-call and night hours – not to mention pay increases within the framework of the Ségur de la santé. Why do we have the impression that nothing is changing?

The situation in the emergency room is only a reflection of the broader state of the hospital. If the emergency rooms are congested, it is because there are no beds to hospitalize patients. This shows that the establishments are undersized, due to a lack of staff. Not to mention that with activity-based funding, which requires a multiplication of procedures, the managers of the various departments are often not inclined to take in patients arriving from the emergency room, especially if they are elderly or have multiple pathologies, because they fear that these patients will remain hospitalized too long and “block” beds. As we know, hospitals are caught up in a race for more profitable technical procedures, which does not at all meet the care needs of an aging population suffering from chronic diseases. With this difficulty in finding downstream beds, emergency room caregivers, who already have a very difficult and undervalued job, feel that they are mistreating their patients. Some people crack, end up leaving, and the difficulties get worse.

READ ALSO: “Ethically, it’s unbearable”: investigation into the great misery of French pediatrics

On the other hand, at the entrance to the emergency room, we continue to pay for the removal of the obligation to participate in on-call care for private doctors (Editor’s note: those who work in the city or in clinics) in the early 2000s. Since then, patients have had more and more difficulty finding a medical response in the evening and on weekends. We cannot blame parents who are worried because their child has a fever at 9 p.m. for coming to the emergency room, even if what they need most is access to unscheduled consultations.

The prefects could requisition doctors but they don’t. As a result, we did indeed invent SAS, healthcare access services: patients can call 15 to get medical advice and be directed to an appropriate response. But this poses a whole series of difficulties. First, we pay – around 100 euros an hour! – general practitioners to come and participate in the operation of 15. But during this time, they are not in their offices receiving patients. We have done better in terms of relevant allocation of resources… And furthermore, a survey by the Samu Urgences de France union showed that the “answer” times of 15 had nevertheless increased in places, because they were receiving too many calls. This puts patients suffering from life-threatening emergencies such as heart attacks or strokes at risk, where every minute counts.

In your book, you advocate for the implementation of a maximum number of patients per nurse. How would this help to resolve the current difficulties?

We are convinced that caregivers would return to the hospital in large numbers. Many paramedical staff left because of their poor working conditions but would be willing to return if they improved. We are not just talking about salary or RTT, but about an environment that allows them to treat patients well and to practice their profession properly.

READ ALSO: To resolve the emergency crisis, fewer audits, more managers!, by Mathias Wargon

We have more and more studies confirming that with ratios, we can very quickly increase the quality of care. In California and Australia, this type of measure has helped improve the quality of life of caregivers, and therefore reduce turnover – you can’t imagine the time, and therefore the money, that we spend here training staff who then leave very quickly. With these more stable teams, with fewer absences due to sick leave, a reduction in complication rates during hospitalization has been observed, as well as a reduction in re-hospitalizations and mortality.

A bill has already been adopted to this effect, where is this text today?

This was a proposal by Socialist Senator Bernard Jomier, which was voted for quite widely on 1 February 2023, across all political tendencies, by his colleagues. This text could be taken up quite quickly by the National Assembly, because all the scientific data shows that this would quickly change the situation for our fellow citizens.

Such a reform would nevertheless risk being complex to implement: some have mentioned potential closures of services if the ratios were not respected due to lack of recruitment…

This reform would not become effective overnight. It will take time to define the right ratios, with the High Authority of Health and the learned societies, which bring together medical experts from different disciplines. Senator Jomier had planned a gradual application, spread over four or five years.

READ ALSO: Staff, autonomy, robots… Shock treatments to save the hospital

The corollary is that we must protect the budgets needed to finance the additional payroll, and therefore remove salaries from activity-based pricing (Editor’s note: the current method of allocating hospital resources). This is what Germany did recently. Could we imagine a fire station paid according to the number of fires?

But where would we find the money to finance these additional staff?

I am not convinced that we really need a considerable increase in the resources devoted to health. Let’s start by hunting down unnecessary procedures, generally estimated at 20% of expenditure. That’s colossal! Why are surgeons paid by Social Security to operate on varicose veins, when this procedure is most often performed for purely aesthetic purposes, and whose medical benefit has not been demonstrated? Why do we accept that the large groups that are currently buying up radiology practices are pushing them to do MRIs, which are better paid, than ultrasounds, and this without medical justification? Why do we continue to tolerate overprescriptions of antibiotics or proton pump inhibitors (PPIs, used for digestive disorders), beyond all recommendations?

READ ALSO: Hospital crisis: where are there the greatest shortages of doctors? Department by department update

Some doctors brandish the freedom to prescribe whenever this issue is raised, but the reality is that we are in the era of evidence-based medicine, and respecting scientific data to offer patients the best possible quality of prescription should be a basic requirement.

Alain Juppé had tried at the time to make the recommendations of good practices enforceable, but the Council of State had rejected the measure…

He had planned financial penalties, that’s the point that was rejected. But there are other methods of sanctions, audits, delisting… That would require resources, but look at all the money devoted to the operation of activity-based pricing: a public agency sets the rates for procedures, hospitals pay coders and consultants to “optimize” the coding, Social Security monitors to prevent the “overvaluation” of procedures… All this bureaucracy is very costly!

READ ALSO: “A crazy logic, which had to lead to a crisis”: why the hospital is cracking

The “100% Social Security”, which would aim to entrust the management of all reimbursements to Health Insurance, could also free up resources, at a constant cost for citizens. Having a double payment (partly by Social Security and partly by complementary health insurance) also costs us a lot: we pay twice for the management of the reimbursement of our care! Not to mention that private organizations must also finance their marketing expenses and, for insurance companies, their shareholders. This subject had been opened by Olivier Véran when he was Minister of Health, but Emmanuel Macron had quickly closed it. However, various studies show that 100% Social Security would save our fellow citizens around 7 billion euros per year.

All these measures are known, and often quite consensual. However, one has the impression that they will never be adopted…

They require political courage, to confront the representatives of insurers and the advocates of the harshest liberal medicine. But let us not be mistaken: there is a major political issue here. The deterioration of public services, and in particular of the public health service, fuels a very strong feeling of abandonment on the part of the populations concerned. This resentment is a very strong driver of the vote for the National Rally.

(1) Guide to misinformation about our health system, Textuel, small critical encyclopedia, 188 euros, 18.90 euros, published on August 28.

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Dengue fever is a viral disease – an arbovirosis – caused by an RNA virus (flavivirus) transmitted by mosquito bites: mosquitos tiger and Aegypti. The number of cases worldwide continues to increase. It is estimated at 400 million per year among 4 billion people exposed mainly in tropical regions. There are serious forms, with hemorrhagic fever requiring hospitalization. They affect approximately 5 million patients each year, sometimes leading to death (20,000 per year). Cases tend to spread to countries in the northern hemisphere, linked to the migration of vector mosquitoes due to global warming. A few cases of indigenous contamination have already been reported in France.

There is no treatment for dengue fever. Prevention is difficult. It is based on individual protection against mosquito bites or collective measures (drying up water points, insecticides but the use of which is restricted by the risks of resistance and toxicity). The release of male mosquitoes rendered sterile could reduce mosquito populations but the effectiveness of this measure remains to be evaluated while it is also the subject of dispute. There are vaccines, but their use requires vaccination screening which complicates their use on a large scale.

READ ALSO: How vaccination increases life expectancy, by Professor Alain Fischer

Reduce viral transmission

This is where the bacteriological warfare comes in. Normally, the virus ingested by the mosquito passes from its intestine to its salivary glands and is then inoculated by the bite (which provides the mosquito with the food bowl of blood). But within the cells of many insects, a class of bacteria called Wolbachia. We are talking about endosymbiosis. It was found that the presence of this bacteria reduced the mosquito’s life expectancy and, above all, reduced viral transmission. This observation gave rise to the idea of ​​releasing female mosquitoes (the only ones that bite) infected with this bacteria into the wild. The experiments were conclusive. While mosquitoes carrying the bacteria are still found a year later, this approach has led to a 40% reduction in cases of dengue fever in the tested areas. A convincing result because people can also become infected by moving outside the treated areas!

After these experiments carried out in Malaysia more than fifteen years ago, the application was made in a dozen countries: Australia, Brazil, Indonesia, as well as in New Caledonia, treated on a small scale. In Indonesia, these releases led to a reduction of more than 70% of dengue cases and hospitalizations. Note that this approach can also benefit the prevention of infections by the Zika or Chikungunya viruses, also transmitted by these mosquitoes. We can only hope for the very large-scale dissemination of this clever strategy!

READ ALSO: Malaria: vaccination is finally a reality, by Professor Alain Fischer

But recently another discovery has come to broaden this strategy. A Chinese team has identified a new bacteria, “Rosenbergiella”present among others in the intestine of certain tiger mosquitoes. This bacterium also reduces the risk of transmitting the dengue virus. It acts by inducing an acidity in the insect’s intestine that is unfavorable to the virus. Interestingly, this team showed that, in regions of Hunan (in China), where the tiger mosquito carried this bacterium in its intestinal microbiota, cases of dengue were less frequent. Correlation does not equal causation, but tests in nature have also shown that infection of mosquitoes by this bacterium made them resistant to the replication of the dengue virus.

These promising results encourage the carrying out of tests of releasing tiger mosquitoes carrying this bacteria. This is all the more interesting since it can also effectively infect the mosquito. Aegyptithe other provider of arboviruses. This is a research avenue that should enrich the possibilities of using commensal bacteria of insect vectors of viral or parasitic diseases to limit infections. A great prospect for ecological, clean and elegant intervention!

Alain Fischer is president of the Academy of Sciences and co-founder of the Institute of Genetic Diseases

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