Strikes hit the hospital sector

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All the trade unions in France's state-run hospital sector called a nationwide strike on 28 January 2000, demanding improved working conditions, more jobs and budget increases. This was the first time in 20 years that the unions in this sector had issued a joint strike call. The industrial action, the scale of which remains to be seen, had been expected and the issues behind the strike, linked to budgetary restrictions and organisational restructuring are not new.

The French state-owned hospital sector employs a workforce of over 750,000, including nearly 100,000 doctors, and accounts for close to 40% of all health spending. As part of an across-the-board policy of health spending cost control, the state-run hospital sector has been experiencing significant budgetary constraints over the past 15 years.

In August 1999, the government published the so-called "second generation" Regional Health Care Organisation Blueprint (Schémas Régionaux d' Organisation des Soins, SROSS). The implementation of the first blueprint from 1994 to 1998 resulted in the loss of 17,000 hospital beds, and the new healthcare blueprint for 1999 to 2004 should cut or redeploy 24,000 beds out of a total of 275,000. The "downsizing" of hospitals has, to date, mainly been an exercise in adjusting the number of beds officially allowed and the actual number of beds. The fact that this area of leeway has been eliminated means that hospitals will now have to get down to genuine restructuring.

This new plan came at an already delicate period in the hospital sector. In July 1999, the National Health Insurance Fund for Employees (Caisse nationale d?assurance maladie des travailleurs salariés, CNAMTS) had used its "strategic plan ("FR9907197F) to reassert its resolve to cut public hospitalisation spending by FRF 32 billion over five years. The Minister for Health, who was well aware of reactions to these proposals, which would have resulted in the laying off of almost 20% of all hospital staff, asserted that hospital policy was his exclusive jurisdiction.

In November 1999, the French Hospitals Federation (Fédération Hospitalière de France), made up of the heads of state-run hospitals, issued a "warning" to the government and alerted it to the fact that "industrial tension, which was already apparent at the grassroots level, could possibly worsen over the next few months, particularly in those regions which have seen only minor increases in their budgets for some years." This prediction was borne out when all the trade unions in the sector called a nationwide strike on 28 January 2000, demanding "improved working conditions, more jobs and budget increases". This was the first time in 20 years that the hospital unions had issued a joint strike call. The CFDT union confederation stated that "the government has run out of areas where productivity gains can be made and is therefore turning the spotlight on staffing levels. This is eroding working conditions." CGT maintained that "we are all in favour of reorganising healthcare services, but we require the additional resources to achieve it."

Table 1 below lists the main trade unions represented in the state-run hospitals sector and their support in the elections of employee representatives held on 28 October 1999.

Table 1. Results of October 1999 workplace elections of employee representatives in state-run hospitals
CGT CFDT CGT-FO FGAF-UNSA SUD-CRC CFTC SNCH (management) CFE-CGC
% of vote 31.08 29.33 24.4 4.41 4.23 3.46 1.05 0.32
Change from 1996 -0.7 0.71 -0.59 0.88 0.73 -0.17 -0.03 -0.15

In recent years, hospital sector budget constraints have been all the less welcome as they have been exacerbated by the following three government objectives: reducing disparities between regions; ensuring better coordination between state-run and private hospitals; and altering the hospital budget calculation formula.

Reducing disparities

The left-wing government that was elected to office in 1997 recognised the potential major industrial unrest on the horizon and relaxed slightly the budget constraints that had been placed on hospitals since the 1995 "Juppé plan". However, this same government was keen to continue a policy of addressing disparities between regions and redistributing hospital care capacity among them. It therefore set up very regionally-specific overall budget increases. Thus, while the national increase in hospital spending is 2.2% for 2000, this figure is an average of budget hikes ranging from 3.78% in the Poitou Charente region to 1.25% in Ile de France, as indicated in table 2.

Table 2. Rate of increase in hospital spending, 1998-2000 (%)
2000 1999 1998
Whole of France 2.24 2.08 1.44
Ile de France 1.25 1.17 0.35
Paris Hospital Authority (Assistance Publique-Hôpitaux de Paris) 1.08 1.0 0.3

It is aimed to reduce disparities within the regions themselves and also in the Paris region to rebalance hospital capacity in central Paris with that of the suburbs. In the case of Paris, this is to be achieved by raising the budgets of the Paris Hospital Authority, which administers the major Paris hospitals, by only 1.08%. Paris hospitals have been subjected to severe budget controls for the past five years and therefore it is quite logical that industrial unrest in the hospital sector should begin there, as indeed it did in late 1999.

Coordination between private and state-run hospitals

A major private hospital sector exists (with over 300,000 employees) in parallel with the state-run sector. Therefore, the government is keen to coordinate both state-run and private hospital care capacity. The private sector has traditionally specialised in the more profitable areas of healthcare, leaving the state-run hospitals to pick up the more major and costly care. Doctors working in the private sector often maintain their "liberal profession" status and earn higher salaries than their counterparts in the state-run sector. Traditionally, there has been strong rivalry between the private and state-run sectors. Policies designed to coordinate private hospitals with their poorer state-run counterparts are widely perceived as an assault on the state-run sector. The National Association of Hospital Doctors (Intersyndicat national des practiciens hospitaliers, INPH), made up of state-run sector hospital doctors, called a nationwide strike for 27 January - the day before the strike called by the other unions - in protest at a government hospital policy resulting in the "surrender of state-run hospital market-share"

Altering the budget formula

In order to move away from a funding system calculated in terms of an "overall budget," which did not reflect the reality of the services provided by the hospitals, the government has set up the" medical information systems programme" (Programme Médicalisé de Systèmes d'Information, PMSI), which will use the "homogeneous patient group" (Groupes homogènes de malades, GHM) technique to attempt to identify the reality of hospital services. Hospital funding already depends to some extent on this type of scheme, and will increasingly do so in the future. Hospital staff criticise this formula for not taking into consideration: the "social dimension" of the services provided by hospitals (eg before discharging a patient from their care, should hospital staff pay attention to his or her housing conditions?); those expenses related to public services provided by hospitals (emergency care, training); and the specific nature of "cutting-edge" activities.

In order to paint a comprehensive picture of the reality of the hospital sector, the government's assessment must take account of an increase in emergency services. The rise in the use of emergency services - currently between 5% and 6% a year - is partly linked to increased poverty. (The increase in the patient load of emergency rooms, which offer 24-hour services, exempt from pre-payment, is certainly tied to the increase in poverty. However, observation of the real situation indicates that other causes, in particular those linked to the breakdown in the family medicine system, are also implicated in this significant increase.) The lack of resources to cope with this increase resulted in emergency service staff being at the forefront of the industrial action in late 1999.

Commentary

Hospitals in France, as in the other European Union countries, are facing major changes. An ageing population, the emergence of new diseases and new techniques of care, along with poverty, are all already combining to change significantly both the requirements of the population and the resources needed to deal with them. In addition, those who in the past were mere "patients" are increasingly behaving as consumers (as evinced by the success of a new "hospital classification" report in France). While there is widespread agreement on the need to reform the hospital sector, debate is focusing on the speed of the implementation of these changes and the resources to be allocated to the process. In the case of France, this debate is complicated by the fact that although the government has the power to distribute financial resources and to restrict budgets, it cannot really dictate how these funds are used (through reorganisation) within a given hospital. Will the current transition to the 35-hour working week (FR9910197N) enable the government to finally broach this issue or will it, in the absence of new funding, just be an additional hindrance? (Pierre Volovitch, IRES)

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