Statism, this incurable and dear French illness | EUROtoday
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EIn France, relating to public coverage, the deep divide shouldn’t be a lot concerning the targets to be achieved as concerning the means to attain them. Thus, within the discipline of well being, everybody advocates equitable entry to care or extols the advantages of prevention. On the opposite hand, if political declarations not often specify the means chosen to attain an goal, historical past speaks for many who have been in energy.
However, the statist camp of each the proper and the left has received. Thus, with one main exception, the well being insurance policies carried out over the previous half-century illustrate the progressive nationalization of France and clarify its paralysis that many want to additional irritate. We all the time want extra State.
Reinforced regulatory constraints
After the creation of the college hospitals in 1958, the main post-war hospital regulation dates again to December 31, 1970. It notably established the well being map, i.e. a planning and authorization system whose acknowledged goal was equitable entry to care. Like the authorization system imagined by Vichy for the opening of pharmacies, any opening of beds, any set up of so-called “heavy” tools has since required prior authorization. This mechanism has been reformed and strengthened many instances, the newest model dates from 2016.
What about a long time later? Nothing, besides the worst: pre-existing inequalities have been maintained, and even worsened. As in 1940, there are nonetheless twice as many pharmacies within the south than within the north of France. More severe penalties, relying on the division or area, the variety of beds per thousand inhabitants is as unequal as in 1970 and, much more telling, the heavy tools that appeared within the Seventies (scanners) or Eighties (MRI), after the well being map, have, relying on the division, a density that varies from one to greater than three. To restrict ourselves to a couple figures, the variety of surgical beds per 100,000 inhabitants is 39 in Eure, 48 in Ain, 176 in Meurthe-et-Moselle and 218 in Paris; for medical beds, nonetheless per 100,000 inhabitants, the hole goes from 109 to 346. The inequalities are much more apparent for locations in nursing houses and long-stay beds.
Despite the apparent failure of this coverage, regulatory constraints have been strengthened. If in 1970, institutions nonetheless had a selection of specialties throughout the main disciplines of drugs, surgical procedure and obstetrics, present planning goes into nice element and plans the beds for every medical-surgical sub-specialty, however this isn’t the principle factor, as a result of the supervisory authority additionally defines, right down to the unit, the variety of jobs in every institution.
The affect of the State has subsequently prolonged since 1970 to different areas, specifically human assets by way of the statutes of the hospital civil service and that of “hospital practitioners” (PH). It follows specifically that, on this context, the remuneration of a physician with the identical seniority can be similar whether or not he practices in Dunkirk or in Cannes, whether or not he’s a surgeon, resuscitation specialist or biologist. This subsequently implies that the director of a public hospital doesn’t have at his disposal domestically the important instrument of any supervisor: the negotiation of remuneration. But that’s not all, the interior group of any public hospital shouldn’t be left to native initiative, however can be outlined by texts.
Before the Second World War, Winston Churchill mentioned that in England every thing was allowed, besides when it was forbidden; in Germany every thing was forbidden besides when it was allowed; within the Soviet Union, every thing was forbidden even when it was allowed, whereas in France, lastly, every thing was allowed, even when it was forbidden! Since then, water has flowed within the Channel and, so far as its well being group is worried, France has grow to be Soviet: every thing is forbidden there.
To be satisfied of this, one solely must learn the regulation of 26 January 2016, introduced to Parliament by Marisol Touraine, then Minister of Health, and subsequently voted on by the left-wing parliamentary majority of that 12 months. In 227 articles, on 111 pages of measurement 8 font, this regulation claims to control well being coverage in its smallest particulars. One article – Article 204 – even imagines the way it may very well be “simplified”, as if a delegation of energy wouldn’t permit, at any time, to “simplify” and not using a regulation and and not using a decree!
This doesn’t appear to be sufficient: two famend docs just lately proposed to “define in the law, for each specialty, a maximum number of patients per nurse and nursing assistant…”. We add Kafka to Cioran! Not solely would this suppose that, like industrial manufacturing, there could be a deterministic hyperlink, a manufacturing operate, between human assets and the standard of care, however above all that drugs wouldn’t change. Can we think about a debate in Parliament after any medical discovery that might modify a remedy and subsequently have an effect on this ratio?
Need for extra self-management
There is one exception to this bureaucratic straitjacket that’s being tightened on daily basis: activity-based pricing (T2A). It was doable to implement it because of the medical classification system for hospital stays developed after I was director of hospitals in 1986 (the medicalization of data techniques program) and, above all, because of the groups of Jean-François Mattei, Minister of Health in 2003. He introduced and had regulation no.° 2003-1199 of December 18, 2003, which permits the hospital to lastly transfer from a logic of means, that of the worldwide finances, to a logic of outcomes: activity-based pricing (T2A). Hospitals are subsequently paid for what they do (surgical procedure, drugs, and many others.) and never for what they’ve (employees, tools, partitions, and many others.).
When doable, budgetary techniques needs to be averted: they’re all the time political, my expertise on this space reveals that cash goes to the highly effective, not the poor. Thus, on the time of the worldwide finances, inequalities between hospitals had been of the identical order because the inequalities of apparatus at the moment: for a similar pathology, the monetary means applied assorted from one to 3 and we weren’t capable of cut back these gaps. More anecdotally, it additionally confirmed that regional stereotypes weren’t completely unfounded: thus the folks of Auvergne had been a lot much less spendthrift than the folks of Provence… In any case, at the moment, because of this method, a coronary heart transplant or a hip prosthesis generates the identical income in Marseille, Clermont-Ferrand, Brest or Strasbourg. This productive equality had by no means been achieved by the worldwide allocation.
However, this methodology has all the time been criticized by part of the medical career, specifically by public sector hospital employees who declare to be left-wing. Thus, in the identical column, these docs declare, with out demonstrating it, that this method managed by a authorities company would outline “profitable” sufferers and others who wouldn’t be. Furthermore, in line with them, “the logic of competition between healthcare players does not allow us to meet the needs of the aging population”. This assertion is empirically questionable: in European nations that aren’t, like France, lucky sufficient to have a big non-public hospital system, the other is noticed: “the aging population” waits greater than a 12 months for a cataract operation or a hip substitute. The absence of competitors creates queues: any public monopoly favors its brokers to the detriment of the folks it’s imagined to serve.
The French ought to subsequently be happy to have a personal hospital sector that performs greater than 50% of surgical procedures and the care of most cancers sufferers! Thus, one may be left-wing and corporatist and never respect having the ability to know the exercise of every and examine it to others. “Benchmarking” is poorly translated into French.
The well being sector doesn’t want extra guidelines, solely extra autonomous and subsequently accountable administration. In France, there are databases (that of medical health insurance reimbursements and the T2A) that make it doable to know exactly the place sufferers are being handled, to explain the care they obtain and to know, at the very least partially, whether or not this care is acceptable. Based on this statement, it’s doable in a area or division to set exact targets for 5 years, three years, then one 12 months and at last to see, with all the private and non-private, hospital and liberal, medical and paramedical stakeholders, elected officers and affected person associations, the right way to obtain them.
This must also be a chance to analyse domestically the prevention strategies that have to be applied once they exist and are efficient. But lastly saying that prevention ought to characterize 10% of well being expenditure, or 25 billion euros (1% of French GDP) is economically not possible and technically absurd, as a result of what are we speaking about: vaccination, screening, well being training, velocity management on the street, taxation of tobacco, alcohol, and even sure meals merchandise? Where, when?
It is true that the general public hospital service is deteriorating, however that’s as a result of there may be an excessive amount of State, too many requirements and no incentives that permit managers to handle and subsequently acknowledge and promote excellence. Michel Barnier's first outing, at Necker Hospital, illustrates the political worth of such centralization. Between him and any hospital, there is no such thing as a delegation of energy and subsequently no competent physique in issues of employment and remuneration. The State monopolizes them whereas it’s clearly incapable of exercising them appropriately by adapting to every particular atmosphere. Indeed, there is no such thing as a justification for treating Necker Hospital, one of many world's main pediatric hospitals, like Guéret Hospital or Nevers Hospital, which lack anesthetists and surgeons.
The French will solely grow to be conscious of the boundaries of nationalisation when political events recognise that the answer to many issues is native and that energy should subsequently be transferred to those that train it at that stage.
* After French coaching in agronomy (INA Paris) and ecology (Engref Paris and Nancy), then American coaching in economics (MBA and PhD at Cornell University), Jean de Kervasdoué was a researcher, instructor, senior civil servant, and enterprise creator. After a number of years on the Assistance publique de Paris and the administration analysis heart of the École polytechnique, he participated as a technical advisor in Pierre Mauroy's first cupboard in 1981. He was then, specifically, the director of hospitals on the Ministry of Health (1981-1986) and, on this capability, on the origin of a number of reforms. International marketing consultant, visiting professor at Yale University, creator of the Pasteur-Cnam college of public well being, he has printed quite a few articles and books on well being techniques and the critique of political ecology. He is a member of the Académie des applied sciences, professor emeritus of the Cnam and journalist at Le Point. His newest work is Health on the rise (humenSciences, 2023).
https://www.lepoint.fr/debats/l-etatisme-cette-incurable-et-couteuse-maladie-francaise-16-09-2024-2570365_2.php