Hospital in crisis: a big boss delivers his thoughts to Agnès Buzin

In an interview with our colleagues in Europe 1, Agnès Buzin, the Minister of Health has noted the inadequacy of the financing system for hospitals in France. The whole system is changing in the opinion of all the actors involved, including the sick. Professor André Grimaldi gives us his thoughts on health expenditure and the public hospital.

Doctors and staff on strike, overwork, activity-based pricing, which will only increase by half of the foreseeable expenses, the hospital is in crisis in France.
The health minister, Agnès Buzyn, spoke on Europe 1, Friday, the need "to invent a new model of funding for the hospital" to "that it is not only funding that pushes to a disproportionate activity ... We need to value the particular competence of hospitals, teaching, research, the ability to do good medicine, the quality of care. " It is also a question of "answering the discomfort expressed especially by the agents of the public establishments of health".
The minister promised that a thorough overhaul was going to be conducted, but noting the magnitude of the task and the complete absence of any embryo proposal in her department when she arrived there, she did not give any calendar.

Against T2A and the "health technocracy"

If she is looking for more realistic skills and ideas than the "health technocracy" of her ministry, she will have no trouble finding them in the hospital itself, where different health actors are dedicated to continuing their work. ensure quality human medicine despite the many administrative obstacles imposed on them.
Seeing that, since its launch, the system of "activity-based pricing" (T2A) went straight into the wall, some think about it and discuss it for a long time in order to involve the entire hospital medical community to this reflection.
Among these various actors in the health of the hospital, some discuss freely on a blog held by Prof. André Grimaldi, a renowned diabetologist at the Pitié-Salpêtrière, in Paris, and slayer of the first hour of the maladjustment of the logic from "the hospital business" to the management of chronic diseases. He agreed to share his thoughts.

Health expenditure in the OECD average

France spends globally 11% of its GDP on health, like Germany, the Netherlands, Belgium, Canada, Switzerland, Austria, Japan ... much more than England (9%), but much less than the United States (17%)
In absolute expenditure per capita, France is the 11th of the OECD countries. We must therefore stop saying that France is the bad pupil of Europe or rich countries

France retreats in the rankings

What is true is that in different rankings, France is declining for two historical reasons:

  • Prevention and avoidable mortality before age 65 (lung cancer continues to increase in women because of smoking): France is at the forefront against endocrine disruptors, rightly, but in the rear for the prevention of complications related to alcohol and tobacco.
  • The social inequalities of health which are also territorial inequalities of health, for lack of having built a health system of proximity based on multi-professional teams of first resort.

Health, a common good

Secu is not an outdated historical model. It was a "genius" construction, ranking health among "common goods", neither state (Beveridge), nor private (mutual private insurance or not).
It therefore benefits from dedicated revenue (contributions, taxes and specific taxes = CSG) and autonomous management. But the expenses of Secu in 1945 were around 2.5% or 3% of GDP, the population was young and relatively healthy, and the allowances were mainly for daily allowances.
Secu was work-related and therefore not universal. In addition it was a compromise with private insurers (mutuals).

A drift of governance

The drift is done towards the stateization of the management and the abandonment of whole sections to the private insurers including the overtaking of fees in the name of the "hole of the Secu"! (Sector 2 was created in 1980 by Raymond Barre so as not to have to increase the prices of doctors in sector 1).
In the spirit of "common good" health, it would be today

  • To distinguish between national solidarity (reimbursed 100% by the Sécu), of what does not depend,
  • Apply the golden rule of mandatory balance of accounts by increasing dedicated revenue and / or decreasing expenditure,
  • To set up co-management (State / professionals / users / social partners).

The organized contradiction

Public hospitals are currently experiencing a contradiction (once again wanted): they are condemned to profitability, like a private clinic (for-profit or not), but they can not choose their medical activity on criteria of profitability and their staff "enjoys" employment guarantee status (which, it is true, some people abuse).
Unlike the private sector, public officials are not contractual with a revisable job and a variable salary.

And we have thanks to our status of official kept a freedom of speech and criticism that do not have the doctors exercising in private clinics. There is an ESPIC facility where the director can tell "his" vascular surgeon: "I want 500 varicose veins a year! And the surgeon answers: "Well, sir, the director." The CEO has replaced the Mandarin!
But there are two main differences in principle between a public hospital and a private clinic (for profit or not).

Private must be profitable

A clinic must be profitable and, to do this, it selects its activities, which can not and should not do the public hospital. A doctor remembers Foch and his transfer to the Institut Mutualiste Montsouris (IMM):
I remember that a long time ago, I saw my diabetics from the IMM arriving ("they do not want us anymore!").
I remember that there was a question one day of closing the internal medicine of the IMM. I remember that at the IMM, urology patients were sorted by telephone by a "regulating doctor". For what, today the IMM has an excellent medical reputation (including in diabetology).
I remember that when I arrived in Saint-Joseph, the new director closed the AIDS service (forgetting to warn the patients) and they were welcomed at the public hospital.
The vaginal delivery is not profitable. As a result, private maternities close or push the indications for cesareans ... Conversely, the public hospital can not go bankrupt and be sold privately, to carry out a real estate operation and / or enter the fold of the international chains of private clinics (I am reminds of the fear of FOCH to be bought by Générale de Santé, itself bought by Ramsay)
It is no coincidence that the therapeutic education of the patient was born, basically, and developed in the public hospital, which had a global budget, and not in private clinics. It is not the fault of their doctors, but of the funding system.

The Public pursues a long-term mission

The public hospital must be efficient, not from the point of view of the institution, but from the point of view of the society (and in this case the Secu). The current system that aims at the profitability of the establishment, regardless of the long-term interest of the Sécu, is "normal" for a private clinic but is deeply absurd for a public hospital. "I was not asked to save the security but to rectify the accounts of my institution," confided a director of ESPIC.
From this point of view the last health law defining the public service by its global missions and obligations and not by its status, paved the way for the gradual change of status of the public hospital, starting with the UHC (as the proposed Francois Fillon). Some CHU directors and some surgeons in public hospitals aspire to it. The former would have more power and the latter would be better paid.

Find the philosophy of CHU creation

Finally, the great Debré reform of 1958, which created the University Hospital Centers, saw its defects prevail over its qualities since the end of the 1980s, as some of its founders had analyzed at the 1996 Caen colloquium ( organized by the Dean Gerard Levy): break with the city, often unjustified separation between PH and PU-PH, devaluation of the clinic and teaching for the benefit of scientific publications, insufficient means of clinical research, confusion and multiplication of tasks (care, research, teaching, management, public health) that could no longer be provided by a person, but by teams.
Today in a CHU there is no reason that a department head is automatically a PU-PH rather than a PH ... In Nantes, the endocrinology department has a PH as head of department and has 2 PU PH).
In short, we must not seek to bring together the self-proclaimed "elite" but the entire hospital medical community. Nostalgia is bad counselor!

But, according to André Grimaldi, the absolute urgency seems to be over to end with the "hospital-business" put in deficit by a progression of the ONDAM lower than the programmed progression of charges!