New law to improve regional healthcare system and patient care

The law on reforming the regional healthcare system and hospital organisation in terms of patient care came into effect in July 2009. The law draws on a report published in 2008 and makes provision for the modernisation of healthcare facilities. It also seeks to address the issues of universal access to quality healthcare and prevention. The trade unions have not uniformly welcomed the law and have denounced unfair competition between public hospitals and the private sector.

The law on reforming the regional healthcare system and hospital organisation in relation to patient care (Loi no. 2009-879 portant réforme de l’hôpital et relative aux patients, à la santé et aux territoires) took effect on 22 July 2009. The law is the result of a long process following the 2004 and 2007 hospital plans, and the remit of the consultation commission created on 16 October 2007. The hospital consultation commission was chaired by the former minister of labour, Gérard Larcher, who is currently President of the French Senate.

For almost 10 years, hospitals in France have been the scene of tensions primarily caused by public authority management difficulties rather than worsening health problems. The reorganisation of healthcare (FR0001136F), the improvement of working conditions (FR0004156F), changes to working time (FR0109101F) and the various legislative changes all have gathered pace since 2004 (FR0402104N) and have triggered industrial action in public (FR0804049I) and private profit-making hospitals (FR0610029I). In fact, hospital staff were particularly involved, as shown by the 2004 (FR0402105N) and 2008 (FR0803019I) workplace elections.

Report by Larcher Commission

The Larcher Commission published its final report (in French, 1.3Mb PDF) on 10 April 2009 containing 16 proposals grouped into four areas, namely: environmental impact, regional organisation, management flexibility and responsibility, and teaching and research.

The report’s innovative aspects primarily cover two dimensions:

  • an external, spatial and relational dimension concerning hospital mergers, including those of different types of hospitals, as well as forging links with other healthcare staff who do not work in healthcare facilities, and with the regions and the authorities that manage them;
  • an internal dimension covering management procedures as defined by the technocratic term ‘governance’, which provides for managers’ power to be increased to the detriment of workplace committees that become solely consultative bodies.

Provisions of new law

The law on reforming the regional healthcare system and hospital organisation in terms of patient care was in discussion since the end of 2007. It gave rise to a long debate at the draft stage, drawing on the preparatory work, including the work carried out by the Larcher Commission.

The law was finally adopted on 24 June 2009 after a long journey through parliament and arbitration between the French parliament (Assemblée nationale) and Senate (Le Sénat). Nonetheless, the Constitutional Court had to reject the appeals made by members of parliament of the opposition parties before the law could take effect on 22 July.

The law is divided into four sections:

  • hospitals;
  • improving access to healthcare;
  • prevention;
  • regional organisation of the healthcare system.

Recommendations to modernise healthcare facilities

The law incorporates the main recommendations of the Larcher report for the modernisation of healthcare facilities and contains new provisions covering:

  • hospital doctors – the new law changes their conditions of practice. These changes apply to doctors who are already permanently employed in hospitals (known as ‘hospital practitioners’) and to doctors in private practice who wish to work in hospitals some of their time and on an interim basis;
  • hospital managers – the law increases their powers considerably, while the powers of co-management bodies are proportionally reduced, with the ‘executive committee’ becoming the ‘board of management’ and the ‘board of governors’ becoming a ‘supervisory committee’. Doctors’ committees, such as the hospital medical committee (Commission Médicale d’Établissement), will also have less power under the new legislation;
  • hospitals – the law strongly encourages hospitals to organise themselves on a regional basis in conjunction with other healthcare facilities and the healthcare staff working in these facilities. Hospitals are being offered new tools: such as regional hospital communities (Communauté hospitalière de territoire, CHT) and health cooperation groupings (Groupement de Coopération Sanitaire, GCS). Mergers are encouraged between hospitals that are considered to be too similar if they have the same legal status or public-private partnerships if they have a different legal status.

Regional organisation of healthcare system

The geographic organisation of the healthcare system is covered at regional level by Section 4 of the law, focusing on the newly established regional health agencies (Agences Régionales de Santé, ARS). These agencies aim to go beyond the remit of the current regional hospital care agencies (Agences régionales d’hospitalisation, ARH) in order to manage all regional healthcare work, including medical care, medical and social welfare, as well as prevention.

The ARS will also absorb other regional healthcare, social services and medical insurance bodies, which were previously responsible for regulation or monitoring in the sector. The ARS will operate at subregional level in the départements regarding medical and social welfare services or in ‘healthcare areas’.

Following the example of the new hospital managers, the future ARS managers will gain increased powers, meaning that they will sometimes be known as ‘health prefects’. Consultative bodies working alongside the ARS will see their power significantly reduced, just like in hospitals. Examples in this regard include the regional health committees, the Conférence régionale de santé and Conférences de territoire de santé.

Universal access to quality healthcare

Section 2 of the hospital reform law on ‘universal access to quality healthcare’ complements the concept of a regional healthcare organisation. It focuses on ‘healthcare provision’ delivered by other non-healthcare facility staff, aiming to reduce healthcare access inequalities in particular. Regional disparities in healthcare provision are currently increasing in France, with some regions becoming ‘medical deserts’ while other neighbouring regions have an excess of healthcare provision.

The law also proposes a number of measures seeking to improve the distribution of healthcare workers across the country. However, these mainly incentive-based measures are likely to be ineffective, as coercive measures proposed in the past have often been dropped due to doctor protests in private practice. The law makes provision for improving the organisation of these healthcare workers by creating professional associations and suggesting ongoing training schemes known as ‘continuous professional development’.

Moreover, the most obvious abuses of patients – such as exceeding set fees, refusing care and discrimination – are now slightly more controlled.

Prevention and public health

Finally, it should be mentioned that Section 3 of the law on ‘prevention and public health’ is considered rather out of step with the law as a whole. Following some progress, particularly with regard to therapeutic patient education, this section lists a number of small-scale measures restricting the consumption of tobacco and alcohol, and combating the causes of obesity. This section seems to fall well short of what was originally intended before the various lobby groups intervened. It is far shorter than the other three sections and seems to be rather a means to mention the notion of prevention in this law.

Trade union reactions

The elaboration of this law has lasted almost two years, marked by many different announcements and some consultation processes. Nonetheless, trade union reactions have been scattered during this period. In fact, there is no steady coordination between the many patients’ associations and trade unions. The associations representing patients’ interests vary widely, depending on the disease concerned, and are not united together in an efficient manner.

Moreover, trade unions in the healthcare sector are as divided as the French trade union movement in general: their membership domain depends on the workers’ status (private or public sector), whether they are physicians or non-physicians, their medical specialisation, and whether they are administrative or technical staff, executives or agents at baseline. Trade unions in healthcare also depend on the major trade unions that dominate the national scene. Furthermore, the healthcare sector is also characterised by corporatist clashes between hospital managers and hospital doctors, involving power struggles.

In the private sector, the majority of trade unions representing doctors in private practice have organised several protest actions when it was first intended to regulate their activity. As the legal provisions in their regard were reduced, they ceased protesting. The minority General Medical Union (Syndicat de la Médecine Générale, SMG) was one of the few trade unions to denounce the shifting focus of general medicine from patient care to procedures, as well as the emergence of unfair competition between public sector hospitals and the private healthcare sector, with the former inevitably losing out and diminishing in size.

These reactions have led to the emergence of a few social movements on several occasions; however, they have led neither to debates on what really matters in this law, nor to significant changes in its substance.

Commentary

The underlying logic of the law is unclear, while it is implicit in its desire to boost groupings centring on healthcare facilities and their managers. In fact, the new law primarily regulates hospitals and the regional organisation of the healthcare system, with the care and patient aspects being of lesser importance.

Overall, the sheer range of interested parties and interests at stake has not enabled constructive critical analysis or the issuing of alternative proposals. Such activities are considered necessary in order to counter what is often perceived as a continuation of the ‘dismantling’ of the public healthcare system to the benefit of profit-motivated private sector players.

Étienne Lecomte, Institute for Economic and Social Research (IRES)

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