Reform of health: we were waiting for the Debré 2 plan, we had a list that keeps the goat and the cabbage

A new health reform, with some ideas, but that does not solve anything for the hospital and keeps the lobbies alive. We are far from the Debré reform (which launched France in medical modernity in 1958), according to Professor André Grimaldi.

The reform that will transform health in France for the next 50 years was finally presented. The reactions are various and mixed, which, in itself, is not surprising in a corporatist country, but above all, we were waiting for meaning and we had a list of 54 measures. Professor André Grimaldi, agitator of ideas for health reform delivers his analysis.

A good diagnosis

The medical system suffers from 3 chronic ailments: 1) the overload of hospital emergencies, 2) the deficiencies in the management of chronic diseases and their prevention, and 3) the medical deserts.

The causes: the lack of coordination between the city and the hospital, the insufficiency of a real multi-professional team work, the insufficient graduation of care in the city and the hospital, the "all T2A" and the "any payment to the act", lack of relevance of prescriptions and acts, excesses of "medicine-business"

A good decision: the end of the current "numerus clausus"

But an ambiguity: let more or less believe that there would be more selection and speak only of "bridges". The blur could lead the evil spirits to believe that there is a wolf!

It is necessary to suppress the P1 and to organize the entry into medicine from the existing university tracks with quotas towards the medicine in 1st, 2nd and 3rd year of license.

But what do the deans say? Are they ready to lose the means afforded to the faculties of medicine that dear, very dear, P1.

Measures that go in the right direction for the city but very insufficient

Coordination of territory (professional communities of territory, say "CPTS") to volunteering, support for the development of health care homes multi-professional, creation of medical assistants, but nothing on health centers and especially not much on payment to act, a real obstacle to teamwork, which involves shared tasks, and a real obstacle to freeing up useful medical time by delegating tasks to "clinical" nurses and real needs of patients.

A real risk: relativize the place of the MSP and health centers in the CPTS while "to make the link, it takes a place".

No more doctors in 2022 will work in isolation. Nice promise but hollow enough if it is not specified because no liberal doctor claims to work in isolation!

For medical deserts, minimal measures

The transformation of local hospitals into "City / Hospital Proximity Hospitals" for geriatrics, follow-up care, tele-medicine, biology and basic imaging with the support of city or hospital specialists for advice or specialized consultation and the hiring of 400 MG volunteer officials.

For nurses

Pursuit of the universitarization of the training and the creation of the master of "advanced practices" and recognition of professional practices.
VERY GOOD ! But what status? What remuneration? To date, no answer.

For the hospital

Graduation of support in GHT. And possibility for commercial clinics to participate in GHT. Return of the hospital "services" (word that the Bachelot Law had wanted to erase) and of the "medical power". An expected hug and welcome! Relevant T2A Critique for Chronic Disease. Payment at the time of care for outpatient surgery. "Fixed price" for diabetes and kidney failure. Hospital package in the first place, called to become a payment to the "course of care city-hospital".

A mechanic surely very attractive when we do not answer the following questions:
• Who decides on the singular path? The attending physician? HAS? The patient ?
• How many packages per pathology and multi-pathology given the extreme variability of patients and the evolution of pathologies?
• How much? Who manages it? CPTS? The secu ? The ARS? The Hospital?
• Which key of distribution between the actors?
• What are the salaries of professionals and institutions?

The word "annual global endowment" (modulated according to the activity and the patients, with shared interest of the teams, the establishment and the Secu) is banned. Why ?

We go headlong, all in chorus, in payment for quality (indices!) And relevance ("we will pay the surgeons who do not operate!"). We are smarter than the Americans and the English who draw a negative balance of this process called "P4P". We did a preliminary study whose results are negative. So very logically we accelerate!

For the salary of nurses and caregivers: NOTHING!
To unlock overtime funding: NOTHING!
New status of hospital practitioners with non-caring valences: VERY WELL! But, at the same time, less full time and more partial time, more mobility city-hospital and hospital-city and more contract workers. The risk is clear: in the name of the fluidity and the modernity not the law DEBRE 2 but the questioning of the fundamental progress of the order DEBRE 1: the full hospitable time. It would be a very nice gift to the private non-profit or commercial: the completion of the dissolution of the public in the large health market.

NOTHING about the income disparities of professionals between disciplines and between the public and the private sector! This disparity does not create a Brownian movement, it creates a natural flow from the hospital to the city, and poorly paid specialties in sector 1 to well-paid specialties and sector 2.

In the name of modernity, a huge leap backwards. The announced end of the T2A and triumph of his policy. History has accustomed us to this kind of ironies

A derision: an ONDAM 2.5 instead of 2.3 or 400 million more

It is three times nothing, given the ambitions displayed, and it is for the city, not for the hospital whose accumulated deficit in 2017 was 900 million euros (which did not prevent the 1st Minister to lower the T2A rates again in 2018 by 0.5%). It is claimed to cure the hospital by treating the city. Perfect, but it is a long-term treatment that will take 10 years or more to bear fruit.

And in the meantime what measures for psychiatry? What measures to stop sleeping in ERs on stretchers? To improve the working conditions of hospital staff?

As for the 3.4 billion in 4 years what is it? A redeployment of sums already committed or additional endowment?

By dint of waiting for its cure by the city, the public hospital will have time to die!

Ways to review the allocation of resources at the risk of hitting lobbies

• The relevance of care: what do we do? The systematic dosage of vitamin D is 100 million euros per year!
• The limitation of pensions: homeopathy is 200 million euros of national solidarity paid to Boiron
• The cost of generics in France: 2 times higher than in England, it is 1 billion euros ...
• The end of the double management Social Security (AMO = 7 billion euros) and complementary private insurance management (AMC = 7 billion euros) would be several billion savings.

The government has made a VERY GOOD decision in the poverty plan: the merger of complementary health assistance (ACS) with CMUc. The CMUc gives the right to the insured to choose the Social Security as Complementary what they do at 90%. By its decision, if it maintains, the government allows 4 million citizens entitled to the ACS to choose Social Security as Complementary (as for the Alsace-Moselle regime).
Why not generalize this very good idea and eventually transform the very expensive complementary into additional?

Finally, this health plan is marked by a concern not to offend anyone, to satisfy the liberals in the city while consoling the hospital, with big words and small measures. All the art of offering everyone "win / win", at the risk of too much hugging ... We expected Debré 2 ...