The Failing French Health Service

Several groups of doctors are striking in protest against conditions, funding, and quality of care.

Amid other recent social movements and protests in France, from the gilets jaunes to a pensions row, several doctors' strikes are now taking place in the country. These strikes are largely predicated on concern regarding the working conditions in public hospitals, which are under the direct control of the state and have suffered from years of austerity.

In a petition openly published in December in the weekly French publication Journal du Dimanche, senior doctors urged the government to develop an improved plan to save the public hospitals. They declared that they would go on strike and cease their non-medical administrative responsibilities by Jan 14, should there be no negotiations. France's Minister of Health, Agnès Buzyn, is yet to meet with the signatories. The petition had been signed by more than 11 400 health professionals at the end of December, including 600 chiefs of service.

The petitioners are demanding concrete measures to ensure that quality of care is maintained, such as a re-evaluation of hospital staff salaries, improvement of the availability of beds and staff, revision of the mode of financing for each service that has administrative costs, and annual reviews on employee satisfaction for each hospital.

Professor André Grimaldi, an endocrinologist at Pitié-Salpêtrière University Hospital in Paris, and a signatory, said the threat was unprecedented.

The HPST law, also known as the Bachelot law, was announced in July, 2009, to restructure hospitals, leaving hospitals deeply indebted and unable to handle the demands of reorganisation while meeting acceptable standards of care for patients, according to Grimaldi.

The petition comes as health-care workers in France have been demonstrating. The strikes began after a patient was aggressive towards a nurse at Hôpital Saint-Antoine in Paris, resulting in paramedic staff going on strike in March, 2019, and quickly spread. A strike by thousands of hospital staff took place in Paris on Nov 14, and on Dec 17 doctors across France went on strike. By Dec 1, 268 hospitals and their paramedic staff across France were involved in strikes, denouncing the restricted hospital budgets and the closure of beds, and demanding adequate salaries to preserve the excellence of care.

The ISNI, which represents a total of 27 000 interns across France, is also planning a national strike for Jan 20 in Paris, following two earlier strikes held in Paris during December. These junior doctors are requesting an investment in health and in the education of its professionals, as well as for their work hours to be counted by hours, not half-day shifts, to permit them to more precisely keep track of overtime spent on administrative tasks. They also demand a re-evaluation of their salaries, and a report on measures undertaken to reform their education. The demands were received on Dec 12 by the director of the cabinet of the ministry of health and of higher education (with no response yet).

In mid-December, interns decided to go on an open-ended strike at La Timone, one of the nation's largest hospitals situated in Marseille. Organised by the Autonomous Union for Interns in Marseille, interns are demanding better education. “The quality of education has degraded, with us junior doctors working overtime to fill in the gaps and performing menial administrative tasks at the expense of the quality of our continued education”, says Léonard Corti, general secretary of the ISNI and a junior doctor working in public health at a Parisian hospital. Interns account for much of the continuity of care in hospitals, providing cover for weekends and night shifts. “Public hospitals are critically understaffed, with a total of 27% of medical positions in public hospitals vacant in 2018. It is us junior doctors who keep the public hospital turning, with no appreciation and respect or a commensurate salary”, says Breysse, president of the ISNI. Junior doctors in training in France make an average of €2600 a month and work long hours. The situation in public hospitals is endangering not only the level of education of doctors in training, but also putting their health at stake. “A third of junior doctors are suicidal and suffering from depression”, according to Corti, who says that several interns die by suicide every year. The health ministry is to meet hospital employee representatives in January.

Public hospitals have been operating at a deficit since 2017. Costs have been increasing by 3·5% to 4·0% annually, while the budget has only increased by 2·4%. “Among European countries, France paradoxically spends among the highest percentage of its GDP on health care overall, but when it comes to the public hospital it is the country that spends the least, with 3·6% of its GDP allocated to hospitals compared to a 4·1% European average”, Dormont told The Lancet. “The budget allocated to the hospital is becoming less year by year, and the budget for 2020 is very restrictive.”

The lack of resources to attract sufficient health-care workers is affecting the quality of education of trainee doctors concerned for their future as health-care providers, according to Justin Breysse, president of the InterSyndicale Nationale des Internes (ISNI), the national association for junior doctors (interns). The public hospital, formerly a coveted place in which to work and which all trainee doctors must pass through, is no longer attractive as a workplace.

Public hospitals are “hanging by a bare thread”, according to a letter written in November by the Federation of Hospitals of France (FDH) to President Emmanuel Macron. The FDH unites 1000 hospitals and 3800 medical–social establishments, such as retirement homes, across France. The FDH declared that Macron's health-care plan, Ma Santé 2022, initially presented in large parts to the council of ministers in February, 2019, falls short in its objectives to alleviate the burden of overcrowded hospitals, to improve access to care everywhere, and to restructure the health-care system to better address the chronic illnesses and ageing of its population. The letter calls on Macron to significantly increase the budget allocated in 2020 to all public health institutions, to raise health-care workers' salaries, and to reduce the reimbursement by medical insurance of an estimated 30% of medical procedures that are thought to be unnecessary. The FDH's appeal states that “reducing unnecessary procedures by just 1% each year would free up 2 billion euros”, and demands this amount as a priority for reinvestment.

According to Grimaldi, too many unnecessary procedures squander resources and do not address many of the patient population's needs: palliative care, chronically ill patients in need of a multidisciplinary approach to care, and prevention in general. “We have, in France, neglected prevention and are overly focused on prescriptive treatment, which is insufficient for today's ageing and chronically ill population”, he says.  Grimaldi seconds the short-term solutions proposed by the FDH: “The government must urgently augment the salary for nurses. In France, we are ranked towards the lower end among the OECD [Organisation for Economic Co-operation and Development] European member nations in terms of remuneration for nurses. If the government raises [nurses'] monthly salary by €300 to €500, this would be a first step to make it more attractive for nurses to perform their jobs.” In Paris alone, there are currently 400 vacant nursing positions.

Since 2013, 17 500 hospital beds have been closed down due to budgetary constraints as a result of the austerity measures. According to the FDH's letter to Macron, doctors believe that the politics of reducing the number of hospital beds is partly a reason for the demise of the public hospitals. “As a result of these austerity measures, old people today can be found lying on stretchers in the hospitals while they wait for a bed to free up. And for the first time, the neonatal reanimation unit of Hôpital Necker, which is Paris's flagship university children's hospital, recently had to send a child with bronchiolitis to a regional medical centre over 200 kilometers away”, Grimaldi told The Lancet.  The debt of all public hospitals in France is estimated at €30 billion, and in November, the government promised €10 billion over the next 3 years to help relieve this debt. It also promised an additional €1·5 billion to aid public hospitals in its health budget for 2020–22.