Representativeness of the European social partner organisations: Hospitals – France
The aim of this representativeness study is to identify the respective national and supranational actors (i.e. trade unions and employer organisations) in the field of industrial relations in the hospital sector in France. In order to determine their relative importance in the sector’s industrial relations, this study will, in particular, focus on their representational quality as well as on their role in collective bargaining.
1. Sectoral properties
| 1994 | 2005** | |
|---|---|---|
| Number of employers | 3,284 | 2,856 |
| Aggregate employment* | 1,088,999 | 1,126,533 |
| Male employment* | 268,872 | 290,276 |
| Female employment* | 820,127 | 836,257 |
| Aggregate employees | 1,025,755 | 1,064,274 |
| Male employees | 243,029 | 247,913 |
| Female employees | 782,726 | 816,361 |
| Aggregate sectoral employment as % of total employment in economy | 4.7% | 4.5% |
| Aggregate sectoral employees as % of total number of employees in economy | 5.2% | 4.7% |
Notes: * Employees plus self-employed persons and temporary agency workers. ** Or most recent data.
Source: National Institute of Statistics and Economic Studies (Institut national de la statistique et des études économiques, INSEE) and the Directorate of Research Analysis and Statistics (Direction de la recherché, des études, de l’évaluation et des statistiques, DREES) of the Ministry of Labour, Labour Relations, the Family, Solidarity and Urban Affairs (Ministère du Travail, des Relations sociales, de la Famille, de la Solidarité et de la Ville)
The French hospital sector is composed of two subsectors. On the one hand, it comprises the public hospital service, which includes public hospitals – whose staff are civil servants – as well as private non-profit-making hospitals, which are called ‘Public service hospital participants’ (Participant au service public hospitalier, PSPH). On the other hand, the private sector includes private profit-making hospitals, which are called private clinics. The figures in Table 1 cover both subsectors.
2. The sector’s unions and employer associations
This section includes the following trade unions and employer organisations:
- trade unions which are party to sector-related collective bargaining;
The following trade unions are representative with regard to negotiations in the public and private sectors, namely the:
- Health and Social Workers Federation (Fédération Santé Sociaux CFDT, FSS CFDT), affiliated to the French Democratic Federation of Labour (Confédération française démocratique du travail, CFDT). It unionises both public and private health, sociomedical and social service sectors. It is the largest CFDT federation;
- Health and Social Services Federation (Fédération CGT de la Santé et de l’Action Sociale, FSAS-CGT), affiliated to the General Confederation of Labour (Confédération générale du travail, CGT). It unionises both public and private health, sociomedical and social service sectors;
- Public Services and Health Services Workers’ Federation (Fédération FO des personnels des services publics et des services de santé, FO Publics Santé), affiliated to the General Confederation of Labour – Force ouvrière (Confédération générale du travail – Force ouvrière). Its coverage differs from the other federations, as it includes those working in local authorities, as well as public and private health, sociomedical and social service sectors;
- Health and Social Services Workers’ Federation (Fédération CFTC Santé et Sociaux), affiliated to the French Christian Workers Confederation (Confédération française des travailleurs chrétiens, CFTC). It unionises both public and private health, sociomedical and social service sectors;
- French Federation of Health, Medicine and Social Services (CFE-CGC de la Santé, de la Médecine et de l’Action Sociale, CFE-CGC-SMAS), affiliated to the General Confederation of Professional and Managerial Staff – French Confederation of Professional and Managerial Staff (Confédération française d’encadrement – Confédération générale des cadres, CFE-CGC). It unionises professional and managerial staff in both public and private health, sociomedical and social service sectors.
The following trade unions are only representative in public sector hospitals:
- National Health and Social Service Workers’ Federation (SUD Santé-Sociaux), affiliated to the Independent Union – Solidarity, Unity, Democracy (Union syndicale – solidaires, unitaires, démocratiques, SUD). It unionises both public and private health, sociomedical and social service sectors. It does not participate in national sectoral bargaining in the private sector;
- Health and Social Service Workers’ Federation (UNSA Santé-Sociaux), affiliated to the National Federation of Independent Unions (Union nationale des syndicats autonomes, UNSA). It unionises both public and private health, sociomedical and social service sectors. It is only representative in the public sector; it does not participate in national sectoral bargaining in the private sector;
- National Union of Hospital Managers (Syndicat national des cadres hospitaliers, SNCH). It unionises managerial staff in public sector hospitals.
- trade unions which are a member of the sector-related European federation, the European Federation of Public Service Unions (EPSU);
Affiliates of CFDT, CGT and CGT-FO.
- employer organisations which are party to sector-related collective bargaining;
There are different employer organisations for the private profit-making sector, the private non-profit-making sector and the public sector. Each employer organisation participates in collective bargaining in its own part of the hospital sector, as follows:
- Hospital Federation of France (Fédération hospitalière de France, FHF). Its membership covers public health establishments;
- Federation of Private Hospital and Assistance Establishments (Fédération des établissements hospitaliers et d’assistance privés, FEHAP). Its membership covers health, sociomedical and social services establishments in the private non-profit-making sector. It is a member of the Union of Non-profit-making Employer Federations and National Associations in the Health, Sociomedical and Social Services Sector (Union des fédérations et syndicats nationaux d’employeurs sans but lucratif du secteur sanitaire, médico-social et social, UNIFED).
- Federation of Private Hospitalisation (Fédération de l’hospitalisation privée, FHP). Its membership covers private profit-making health establishments. It is a member of the Movement of French Enterprises (Mouvement des entreprises de France, MEDEF).
- employer organisations which are a member of the sector-related European employer federation, the Hospital and Healthcare European Employers’ Association (HOSPEEM).
FHF and FEHAP are members of the European Hospital and Healthcare Federation (HOPE). FHP is a member of the European Business Summit (EBS).
2a Data on the unions
2a.1 Type of membership (voluntary vs. compulsory)
All of the trade unions offer voluntary membership.
2a.2 Formal demarcation of membership domain (e.g. blue-collar workers, private sector workers, service sector employees, etc)
The trade unions organise all categories of staff, except for SNCH and CFE-CGC-SMAS, which only organise managerial staff.
2a.3 Number of union members (i.e. the total number of members of the union as a whole)
It is difficult to assess the number of trade union members in France. Apart from the numbers that are declared by the unions themselves and seem to be most probably over-estimated (see the works of Dominique Andolfatto and Dominique Labbé regarding CGT and CFDT), there are no studies on them. However, it is generally agreed that trade union membership rates are low. Although survey data based on people’s statements are rarely used in this way, they can give an insight into unionisation levels. One example of such a survey is the Permanent survey on households’ living conditions (Enquête permanente sur les conditions de vie des ménages, EPCVM), carried out by the National Institute of Statistics and Economic Studies (Institut national de la statistique et des études économiques, INSEE). According to the EPCVM, just under 1.9 million economically active employees are trade union members, that is, 8% to 9% of the total economically active population in employment. The survey does not give information on which unions they are members of.
2a.4 Number of union members in the sector
As explained, it is difficult to evaluate the number of trade union members in the sector. The EPCVM assesses the membership rate in public hospitals at 15%. The overall union membership rate in the private sector is about 5%.
The strength of each trade union in the sector is not known; however, it can be evaluated by examining the results of workplace elections. In the public hospital sector, the results of the last workplace elections in December 2007 were as follows: CGT – 32%; CFDT – 24%; FO – 22.5%; SUD – 9%; UNSA – 5%; CFTC – 4%; SNCH – 1%; CFE-CGC – 0.5%. In the private sector, the results of works council elections in 2005 in the sector ‘Education, health and social services’ (there is no breakdown for the hospital sector alone) were as follows: CFDT – 30%; CGT – 19.4%; FO – 9.6%; CFTC – 7.3%; CFE-CGC – 2.7%.
2a.5 Female union members as a percentage of total union membership
Not available.
2a.6 Density with regard to the union domain (see 2a.2)
See Question 2a4.
2a.7 Density of the union with regard to the sector
See Question 2a4.
2a.8 Does the union conclude collective agreements?
See Question 4 below.
2a.9 For each association, list their affiliation to higher-level national, European and international interest associations (including cross-sectoral associations).
See above.
2b Data on the employer associations
There are no statistics or studies on membership of employer organisations in France. Therefore, it is impossible to answer parts 2b.3 to 2b.10 of this question.
2b.1 Type of membership (voluntary vs. compulsory)
Voluntary.
2b.2 Formal demarcation of membership domain (e.g. SMEs, small-scale crafts/industry, health services, etc)
See above.
2b.11 Does the employer association conclude collective agreements?
See Question 4 below.
2b.12 For each association, list their affiliation to higher-level national, European and international interest associations (including the cross-sectoral associations).
See above.
3. Inter-associational relationships
3.1. Please list all unions covered by this study whose domains overlap.
The domains of all of the trade unions overlap (see Question 2).
3.2. Do rivalries and competition exist among the unions, concerning the right to conclude collective agreements and to be consulted in public policy formulation and implementation?
Given that their domains of unionisation overlap, all of the trade unions are open to competition and to making alliances regarding collective bargaining and consultation in the area of public policy.
3.3. If yes, are certain unions excluded from these rights?
The health federations of UNSA and SUD do not participate in collective bargaining in the private sector.
3.4. Same question for employer associations as 3.1.
The domains of the employer organisations are clearly differentiated, as outlined above.
4. The system of collective bargaining
The French hospital sector is part of both the private and public sectors. Industrial relations are thus covered by two different sets of rules:
- the public sector – staff labour relations come under the rules applying to hospital civil servants and collective bargaining does not exist as such. Instead, there are consultations between the Minister of Health and Sport and the trade unions.
- the private sector – the labour code applies and collective bargaining takes place at sectoral and company levels.
4.1. Sector’s rate of collective bargaining coverage
In the private sector, the ratio of collective bargaining coverage is 100%, given the existence of a procedure of extending collective agreements to the whole sector.
4.2. Relative importance of multi-employer agreements and of single-employer agreements
Not applicable.
4.2.1. Is there a practice of extending multi-employer agreements to employers who are not affiliated to the signatory employer associations?
Yes.
4.2.2. If there is a practice of extending collective agreements, is this practice pervasive or rather limited and exceptional?
The practice of extending collective agreements is systematic in France – and notably for both of the collective agreements in the private hospital sector, namely the one signed by FHP and the one signed by FEHAP. Moreover, in this sector – given that hospital funding depends on the public health insurance system and therefore public expenditure – collective agreements are approved by the Ministry of Health and Sport (Ministère de la santé et des sports).
4.3. List all sector-related multi-employer wage agreements* valid in 2005 (or most recent data).
* Only wage agreements which are (re)negotiated on a reiterated basis. In case of regionally differentiated, parallel agreements, an aggregate answer explaining the pattern may be given.
| Bargaining parties | Purview of sector-related multi-employer wage agreements | ||
|---|---|---|---|
| Sectoral | Type of employees | Territorial | |
| FHP CFTC, CFDT, CFE-CGC, FO and CGT federations | Private profit-making health establishments | All | National |
| FEHAP CFTC, CFDT and CFE-CGC federations | Private non-profit-making health establishments | All | National |
5. Formulation and implementation of sector-specific public policies
5.1. Are the sector’s employer associations and unions usually consulted by the authorities in sector-specific matters?
The sector’s employer organisations and trade unions are regularly consulted by the Minister of Health and Sport about health policy in France – for example, with regard to funding, organisation and hospital governance. The social partners are also consulted regarding industrial relations in hospitals, such as in respect of pay, staffing and working time.
5.2. Do tripartite bodies dealing with sector-specific issues exist?
| Name of body and scope of activity | Bipartite/tripartite | Origin: agreement/statutory | Trade unions having representatives | Employer organisations having representatives |
|---|---|---|---|---|
| Hospital Civil Service Higher Council (Conseil supérieur de la fonction publique hospitalière, CSFPH) | Tripartite | Statutory | CFDT, CFTC, CFE-CGC, FO, CGT, SUD, UNSA, SNCH federations | FHF |
| National Committee on Health and Social Services Organisation (Comité national de l’organisation sanitaire et sociale, CNOSS) | Tripartite | Statutory | All of the hospital unions | All of the health associations |
| National Salaried Employee Health Insurance Fund (Caisse nationale d’assurance maladie des travailleurs salariés, CNAMTS) | Tripartite | Agreement | CFDT, CFTC, CFE-CGC, CGT, FO national trade union confederations | MEDEF, General Confederation of Small and Medium-sized Enterprises (Confédération générale des petites et moyennes entreprises, CGPME) and Craftwork Employers’ Association (Union professionnelle artisanale, UPA) |
Note: * Sector-specific policies target and affect the sector under consideration.
6. Statutory regulations of representativeness
6.1. In the case of the unions, do statutory regulations exist which establish criteria of representativeness which a union must meet, so as to be entitled to conclude collective agreements?
In the private sector, a ministerial decree dating from 1966 attributes representativeness to all of the federations affiliated to the following five confederations: CFDT, CFTC, CFE-CGC, CGT and FO. The federations covering the hospital sector affiliated to these five confederations are thus representative, notably in relation to collective bargaining. The other trade unions must prove their representativeness with respect to both quantitative criteria, such as the number of members and union dues, and qualitative criteria, such as the ability to mobilise and independence. Despite many court cases, neither SUD Santé- Sociaux nor UNSA Santé- Sociaux have succeeded in this regard. However, both federations have won representativeness at the level of specific hospitals where they are well established.
In the public sector, there is a quantitative rule regarding representativeness that is based on the results of workplace elections. Federations that fulfil the conditions are entitled to membership of CSFPH. In the hospital civil service, no collective bargaining takes place, but the Minister of Health and Sport organises consultations with the trade unions on major industrial relations topics, such as pay, training and working time and organisation. All eight representative trade unions participate: CFDT, CFTC, CFE-CGC, CGT, FO, SUD, UNSA and SNCH.
6.2. In the case of the unions, do statutory regulations exist which establish criteria of representativeness which a union must meet, so as to be entitled to be consulted in matters of public policy and to participate in tripartite bodies?
The same criteria apply as outlined under the previous question in the public and private sectors.
6.3. Are elections for a certain representational body (e.g. works councils) established as criteria for union representativeness? If yes, please report the most recent electoral outcome for the sector.
Election results are only taken into account in the public sector. See Question 2a4.
6.4. Same question for employer associations as 6.1.
Representativeness is awarded by the state.
6.5. Same question for employer associations as 6.2.
Representativeness is awarded by the state.
6.6. Are elections for a certain representational body established as criteria for the representativeness of employer associations?
No.
7. Commentary
Please give your views on the issue of representativeness in the sector, especially on jurisdictional disputes and recognition problems, and indicate any specificities or other problems which refer to representativeness in this sector in your country.
In France, expenditure on health represents 9.5% of gross domestic product (GDP). Hospital expenditure accounts for 44% of the total health expenditure, that is, 5.8% of households’ total consumption. Less than 3,000 private and public establishments provide hospital treatment and, since the mid 1990s, the number of private establishments has declined as a result of restructuring. The public hospital service, which includes the public establishments and more than two thirds of private establishments, represents three quarters of all beds and places offered by the hospital system.
The employment status of the 1.1 million employees in the hospital sector is just as varied. They are represented by eight trade unions – seven in the private sector – and only those in the private sector are covered by collective bargaining, whereas those who are civil servants are covered by civil service rules.
Catherine Vincent, Institute for Economic and Social Research (IRES)