General practitioners dispute continues

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Disputes over general practitioners' consultation fees continued in France in March 2002. An agreement on new rates signed in January by the CNAMTS sickness insurance funds and one of the two general practitioners' associations was rejected by other association, which has continued to organise action, such as refusing to work on-call at night or at weekends. Furthermore, a minority of doctors are systematically charging fees in excess of the going rate. Meanwhile, the authorities are continuing to establish a new system of organising the relationship between the sickness insurance funds and doctors, and disputes in other parts of the health sector are still at serious levels.

French general practitioners have been involved in industrial action since November 2001, aimed at obtaining from the sickness insurance funds a major increase in the fees for consultations with patients (FR0201110F). On 24 January 2002, the National Employed Workers' Insurance Fund (Caisse Nationale d'Assurance maladie des travailleurs salariés, CNAMTS) and the two other sickness insurance funds (covering farmers and shopkeepers/craftsworkers) signed an agreement for an increase in fees with one of the general practitioners' trade unions, the French Federation of General Practitioners (Fédération Française des Médecins Généralistes, MG-France). The main provisions of this agreement include an EUR 18.50 fee per consultation, and the introduction of several forms of flat-rate payment (payment for on-call periods and financial aid for setting up a practice).

While thus partially acceding to the demand for an increase submitted by the doctors, the CNAMTS has pressed on with its project of amending the pay structure for general practitioners in which the share of payment per consultation decreases progressively. Anxious to alleviate the tension in the health sector, the Ministry for Employment and Solidarity quickly produced regulations enabling the new price structure to be in place from 1 March 2002.

Challenge to the agreement

The other general practitioners' union, the National Union of French General Practitioners (Union nationale des omnipraticiens de France, UNOF) - the general practitioner affiliate of the Confederation of French Doctors' Unions (Confédération des syndicats médicaux français, CSMF), France's largest organisations of independent doctors - condemned what it termed 'a minority' agreement and continued to press for a fee of EUR 20 per consultation. In support of this claim, it organised two 'no doctor' days, and continued to call for strikes during night and weekend on-call periods. Various groups have interpreted the extent of the mobilisation of doctors differently. UNOF stated that the participation rate in its second 'no doctor' day was 80%. MG France, however, estimated it at 10%. The CNAMTS publicised the fact that on this day, the reduction in the number of electronic transmissions of consultation records by doctors to insurance funds was only 25%. Some general practitioners, certain of whom are members of a 'national coordinating body', have been unilaterally applying a consultation fee of EUR 20. UNOF, however, has made no direct call for this type of excess rate to be charged.

In 2001, four of the trade unions sitting on the board of the CNAMTS - the General Confederation of Labour (Confédération générale du travail, CGT), the French Democratic Confederation of Labour, the General Confederation of Labour-Force ouvrière (Confédération générale du travail-Force ouvrière, CGT-FO), the French Christian Workers' Confederation (Confédération française des travailleurs chrétiens, CFTC) and the French Confederation of Professional and Managerial Staff-General Confederation of Professional and Managerial Staff (Confédération française de l'encadrement-Confédération générale des cadres, CFE-CGC) - and three doctors' organisations, including UNOF, set up the 'Group of seven' (G7). This group demanded the reconvening of talks over a new agreement between funds and doctors, based on a major increase in doctors' fees (FR0105157F).

Three of the unions involved - CFE-CGC, CGT and CGT-FO - have now rejected the MG France-CNAMTS agreement. However, they have also expressed reservations about some doctors' practice of charging EUR 20, more than the going rate for consultations.

CFE-CGC feels that the deal a 'shameful agreement made with a minority union [...] while all the conditions were in place for wide-ranging negotiations on an overhaul of the structure of the relationship between the state, the social partners and health sector professionals'.

For CGT, 'apart from the provisions related to fees, which are actually extremely deficient, the agreement is based virtually on the old type of reasoning which has led to today's situation. The EUR 20 fee per consultation was negotiable. This increase, though, had to be linked with an overhauled medical agreement on the basis of the G7 proposals.' On the subject of the EUR 20 fee being charged by some doctors, CGT talked of 'action that could not receive its support, as the increase penalises the members of the insurance scheme'.

CGT-FO stated that 'health professionals are facing an unprecedented identity crisis. They have been keen on obtaining a dialogue with the relevant decision-makers in the health sector and have not been able to make their voices heard [...] The reactions of general practitioners on the local level, while comprehensible, can in no circumstances be allowed to become the rule. Both the funds and the government now have to exercise their responsibilities and open genuine collective bargaining negotiations involving all the medical professions.' CGT–FO announced that it would take part in a demonstration by general practitioners on 10 March 2002.

The French Democratic Confederation of Labour (Confédération française démocratique du travail, CFDT) which chairs the CNAMTS, has a very different perspective on the agreement with MG France. It feels that although the general practitioners' claims are not unfounded, they have adopted an 'extreme means of expressing' them. The agreement signed with the sickness insurance funds is a 'contract for progress put to the general practitioners', which 'enshrines their pivotal role'. The charging of EUR 20 for consultations, it suggests, corresponds to a 'form of over-pricing [which] challenges the contract that the doctors concluded with the sickness insurance funds'.

Reform goes on

The continuation of unrest among some doctors is going hand-in-hand with continued government action aimed at promoting the reform of the agreement-based relationships between doctors and the sickness insurance funds and, on a broader scale, reorganising the healthcare system. In February 2002, the National Assembly finally passed a law enabling the implementation of a new set of agreements between health professionals and sickness insurance funds. The funds will adopt a 'baseline' agreement with all the healthcare professionals (doctors and paramedics). Beyond this first level, each profession will have a special agreement with the funds. Lastly, health professionals will be able to come to agreements, on a voluntary basis, relating both to commitments on the performance of their work and the provisions on extra fees.

In early March 2002, the Ministry of Employment and Solidarity, the sickness insurance funds and the Order of Doctors (Ordre de médecins- a body, membership of which is compulsory for doctors, and which, among other matter, is responsible for determining medical ethics) agreed on a new system of organisation of medical on-call rosters. The Ministry has additionally begun bargaining with all the medical associations about the future recruitment and training of doctors.

The action taken by general practitioners is part of a context of ongoing disputes in the health sector. Although the sickness insurance funds have signed an agreement with one of the independent nurses' unions dealing, among other issues, with a 10% fee rise, another union (which had signed the previous agreement) is still calling for the 'new patient strike' (with nurses looking after current patients, but not taking on new ones). Paediatricians are still taking industrial action on claims specific to their profession. Lastly and most importantly, the unions representing public hospital employees that did not sign up to the September 2001 agreement on the reduction of working time - CFTC, CGT, CGT-FO and Solidarity, Unity, Democracy (Solidaire, Unitaire, Démocratique, SUD) - are continuing to call for the renegotiation of this agreement (FR0110102N). Beyond local actions carried out in various hospitals, they called a day of action and a national demonstration on 12 March 2002.

Commentary

The fact that France is currently in the run-up to parliamentary and presidential elections in 2002 has not helped clarify what is at stake in the health sector. In the short term, the practice of some doctors charging unauthorised excess fees, whose scope is difficult to specify, has posed the question of how to maintain an effective agreement-based healthcare policy in France. Compliance with the rates set by the social security system by all the doctors in the country was achieved only in the late 1960s. This was quickly challenged by the creation of a 'second sector' in which doctors can work for unrestricted fees (with the difference between the practitioners' fees and the sickness insurance fund rates being paid by the patient) while remaining partners in an agreement with the sickness insurance funds. Although the practice of charging large excess fees is set to continue and even be extended, it is the entire credibility of the agreement-based policy between sickness insurance bodies and the doctors, as well as the universal access to healthcare which are being jeopardised. (Pierre Volovitch, IRES)