Strikes in the hospital sector

In March and April 1997 there was major conflict of two types in the French hospital sector. The conflict involving trainee doctors and ward heads was intended as a protest against the medical agreement signed by the social security health insurance funds (caisses nationales d'assurance-maladie) and two medical unions. The other involved a large number of hospital staff who launched protests against budget restrictions affecting hospitals. Both these movements existed side by side for a number of weeks and never really met. The real aims of each were totally different in nature.

The law on social welfare, adopted in November 1995, included provisions on a range of matters, such as: the submission of the social security budget to parliamentary vote; the setting up of a new tax known as "social security deficit clearance" (Remboursement de la dette sociale); the abolition of pension funds relating to specific sectors, which sparked off the rail strike in November and December 1995 and was finally withdrawn; and the setting up of personal health record books. One of the provisions related to the reduction of health expenditure and a reorganisation of the healthcare system. Two types of redistribution in particular were provided for:

• hospital budgets must take account of the institutions' level of activity and allow the elimination of regional discrepancies; and
• doctors should pay more attention to medical expenditure with regard to prescriptions and their own fees. This measure was to be implemented following the negotiation and signing of an agreement between the social security health insurance funds and the medical unions.

The introduction of these two series of measures has given rise to a great deal of social unrest during recent weeks.

The hospital budget provokes reaction

At the end of December 1996, the Government announced its main hospital budget options on a region-by-region basis; for the first time, the budget was not to be uniformly increased. In some regions the budget was increased by more than 1% whereas in others there was to be a reduction - of 0.8% in the Paris area, for example. Furthermore, due to the state of the social security accounts, the overall budget trend is downwards in real terms, as it will grow by only 0.5% in 1997 compared with 2.1% last year. In February and March 1997, as the first consequences of the government decisions were becoming apparent in hospitals, strikes began to break out on a local level. In numerous hospitals and university-affiliated teaching hospitals (CHU) the types of action undertaken were quite radical, including taking managers hostage. At the same time, the Fédération Hospitalière de France (FHF), which represents mayors, condemned these restrictions (mayors are often hospital presidents and as such are often the largest employers in their towns).

In March two healthworkers' unions, the CGT (Confédération générale du travail) and the CGT-FO (Confédération générale du travail-Force ouvrière) organised separately a week of action, culmination in action on 13 and 14 March in which the CRC, which is composed of former members of the CFDT (Confédération française démocratique du travail), also took part. For these unions, it was a struggle directed at the whole "Juppé plan" on social security, and not just at the its financial consequences.

As for the CFDT, which had approved in November 1995 the part of the plan relating to medical insurance, it demanded together with other trade unions (CGC- Confédération générale des cadres, CFTC- Confédération française des travailleurs chrétiens and UNSA- Union nationale des syndicats autonomes) and the doctors' unions, the creation of a "hospital transitional fund" financed by the state and enabling them to face the current restructuring.

Faced with this unrest, the Government decided to make an extra FRF 800 million available. The budget will ultimately be raised by 1.25% and the reduction in funds allocated to the Paris region will be slightly less (-0.5% instead of -0.8%).

However, within the hospitals themselves, another conflict led by trainee doctors against the medical agreement had just broken out.

Medical agreement attacked

On 28 February, after months of negotiation, the social security health insurance funds and the two doctors' unions (MG-France, the largest general practitioners' union and the Union collégiale des chirugiens et des spécialistes français, a smaller specialists' union) concluded two separate medical agreements. One concerned the 60,000 general practitioners and the other the 53,000 specialists. The two texts replaced the former agreement signed in 1993, which was abandoned by the health insurance funds as they were unable to reach agreement on adapting it to the stipulations of the Juppé plan. The new agreements provide for an increase in expenditure (prescriptions and fees) in 1997 of 1.5% for general practitioners and of 1.1% for specialists. As for expenditure covered by social security, general practitioners must abide by an increase of 2.4% for fees and 1.3% for prescriptions, whereas the ceilings placed on specialists are 1.3% and 0.5% respectively.

In the event of their exceeding these percentages, doctors will be forced to reimburse part of their fees and certain sums linked to prescriptions to the social security fund.

The other medical unions including the CSMF (Confédération des syndicats médicaux français, which includes general practitioners and specialists and which is the largest union among the latter), refuse what they call a "rationing of healthcare".

Within hospitals, these agreements are causing alarm amongst many trainee doctors who are already experiencing hospital budget restrictions. There are 17,000 of them and 85% will become private doctors working under the medical agreements in question. They consider that their future is under threat and that their future setting up as specialists will be more difficult than that of their predecessors. On 1 March, the trainee doctors' and ward heads' unions together called a strike for 11 March (ward heads are trainee doctors at the end of their studies who have been selected by head doctors). The Government and the social security health insurance funds immediately opened negotiations which led to the satisfying of trainee doctors' demands on 10 March. They are to be exempt from fines for seven years in the event of their exceeding quotas (prior proposals were for exemption for three or five years).

The trainee doctors' leaders proclaimed victory but were quickly overturned. New teams replaced them with the aim of "overturning the provision for reimbursement where stipulated expenditure is exceeded." The strike spread and continued for nearly five weeks. Demonstrations were organised for 25 March, 3 April and finally 13 April. Gradually, other sectors of the profession joined the trainee doctors. Private doctors hostile to the agreements demonstrated in large numbers alongside them on 10 April. The CGT has also called for demonstrations and FO is supporting trainee doctors and ward heads.

On 15 April, faced with a certain slowing-down of the movement, the trainee doctors' unions decided to stop the strike in order to undertake other types of action (free treatment will be given on 24 April, for example).

Commentary

These different conflicts have once again given rise to serious divisions between unions. The CFDT, faced with the hospital budget situation, has tried to act in such a way as to find local solutions to problems and has asked the state to take facilitating measures. It has been particularly critical of the action taken by trainee doctors. As far as the CFDT secretary general, Nicole Notat, is concerned, the dispute is now a "conservative conflict". For her, the Government should under no circumstances give in to the demands of the trainee doctors, because "if they obtained what they were demanding from the Government then the conflict would be a step backwards for social security". The CFDT is sticking to its policy, which is now two years' old, and considers it necessary to make all of those in the health sector responsible for their actions. It reiterates its attachment to the agreements and to a checking of health expenditure in order to safeguard social security for all without a rationing of healthcare.

The positions of the CGT and of FO are very different. For them, the current conflicts are a direct consequence of the Juppé plan which should be resisted in its entirety, even if this means joining - albeit with the greatest of care and perhaps symbolically - the private doctors and future private doctors. These two unions are going about this in entirely different ways. FO, in a press release on 7 April, stated that the trainee doctors' protests were at the beginning entirely self-interested but that gradually the demands of the future private doctors changed so that today they are attacking the financial accountability set up by the Juppé plan. This is the reason why this confederation supported the demonstration on 13 April.

The CGT, for its part, decided to become involved more directly and to call out its members to take part in the demonstration on 13 April. This had rather mixed results if we are to believe the press, according to which only about 400 of the demonstrators out of a total of 10,000 to 20,000 were from this union. As far as the CGT is concerned, there are other possibilities founded in particular on an efficient social security system, on quality public hospital service, and on "a revised medical agreement negotiated freely and guaranteeing the rights of the beneficiaries and satisfactory working conditions for doctors".

Since the adoption of the Government plan in November 1995, the differences on the subject of the welfare system between the various unions are far from being bridged, and have if anything deepened. (Alexandre Bilous, IRES)