Little by little, patients in Villeneuve-sur-Yonne, in Burgundy-Franche-Comté, had to get used to saying goodbye to the attending doctors who had been with them for years. While this small town of 5,300 inhabitants had seven general practitioners twenty years ago, only one doctor now comes, part-time, to occupy the brand new practice installed on the first floor of the pharmacy, in the heart of the city center. . “We have a lot of trouble getting people to come… And above all, to convince them to stay,” regrets Nadège Naze, the mayor of the town. In 2021, the elected official had to deal with the departure, in quick succession, of her last two doctors: one retired, the other refused to stay alone in the office… and moved to a neighboring town, seven kilometers away. To try to keep the office open, the elected official nevertheless proposed the recruitment of an advanced practice nurse and mentioned a health home project in the years to come. “But that wasn’t enough. My colleague, opposite, offered him a cheaper office rent, to share with other professionals. I couldn’t compete, but I find it a shame that we came to draw the line between mayors to recruit,” breathes Nadège Naze.
For several months, the elected representative has witnessed a real “race to the chase” to try to recruit general practitioners, in a department where the number of doctors has fallen by more than 13% between 2010 and 2023, according to the latest Atlas of Medical Demography. “We organize integration weekends for interns, we show that our territory is attractive, but there are certain financial levers with which I cannot compete,” testifies the councilor. Around its municipality, many territories are classified as urban free zones (ZFU) or rural revitalization zones (ZRR), in which professionals can benefit from tax exemptions for five years from their installation. “I have had many appointments with interested doctors, who slip through my fingers when they understand that they can find something more interesting a few kilometers away… I cannot offer them 10,000 euros of exemption from charges over five years, even if I would really need additional professionals”, testifies the mayor, who continues to desperately look for a possible replacement for her municipality.
“The competition is terrible”
Everywhere in France, the noose is tightening around elected officials, responsible in spite of themselves for recruiting the general practitioners missing from their villages. The situation is even becoming a “real source of concern” for certain city councilors, such as Matthieu Demoncheaux, mayor of Hesdin and president of the community of communes (CC) of the 7 valleys, in Pas-de-Calais. Even though its territory benefits from the contract to aid the installation of doctors (Caim) paid by the regional health agency to those who agree to settle in areas considered under-resourced – bonuses which can reach up to ‘at 50,000 euros depending on the number of days of activity per week – the man is unable to find replacements. “Many of our general practitioners are reaching the end of their careers, and there are already not enough of them to treat everyone. The situation is not yet catastrophic, but could become so,” he warns.
To avoid such a disaster scenario, more than 4 million euros were invested by the CC in the construction of a new health center, the rents of the practices are proposed “at 7.70 euros per square meter”, and platforms specializing in the recruitment of health professionals have even been approached to find the rare pearl. “But nothing helps. We have the feeling that there will always be someone who will offer better than us, the competition is terrible between the territories,” regrets Matthieu Demonchaux. For several months, a young doctor has been hesitating between the CC of the 7 valleys and a neighboring territory, in the Somme. “On the other hand, they are offering free rent for two years… I don’t find that normal, it’s a kind of unfair competition. Soon it will be the house, the free car or other advantages to be lined up… Me, I still refuses to come to that!” the chosen one annoys.
“Unhealthy escalation”
Isabelle Dugelet, mayor of La Gresle (Loire) and member of the board of directors of the Association of Rural Mayors of France (AMRF), no longer hesitates to speak of an “increasingly strong territorial war” in the recruitment of certain attending physicians. “Unfortunately, there is a hunt for bonuses, benefits, sometimes in kind. Some departments or municipalities go so far as to support doctors in their search for homes, places in daycare or school, this is absolutely regrettable,” she laments. At the same time, the councilor observes the “harassment” of certain private health centers, which try to poach private doctors “by showering them with letters, promising them salary, paid leave and a four-day week”. “How can our small communities fight?” asks the mayor, who calls for “an unhealthy escalation to stop”.
In Fresnay-sur-Sarthe, in the Pays de la Loire, Fabienne Labrette-Ménager had the bitter experience of what she also describes as a “race for bonuses”. In 2021, the couple of doctors who had been practicing in their town for twenty years left the area to settle in Saint-Vaast-la-Hougue, in Normandy. In this under-resourced area, general practitioners benefited from an installation bonus of more than 93,000 euros paid by the primary health insurance fund (CPAM). A “helping hand” that does not go down well with Fabienne Labrette-Ménager. “We naively thought they were retiring, but no. They left one under-endowed area for another under-endowed area, pocketing a real jackpot, which really raises questions about the ethical limits of these help,” she says.
In Saint-Vaast-la-Hougue, mayor Gilbert Doucet says he is “aware of a domino effect” and “a race of attractiveness between the municipalities and the different urban areas”, but tries to put things into perspective. “It is also a question of opportunity and career choice: the couple in question had just bought a secondary house in the area, we could make premises available to them for a rent corresponding to the cost price, and the communication between us went well,” he pleads. The fact remains that in Fresnay-sur-Sarthe, the mayor has only been able, since the couple’s departure, to hire a young doctor, who currently works part-time. “More than 1,000 patients are now without a general practitioner, and are not getting treatment,” recalls Fabienne Labrette-Ménager, exasperated.
“Nothing is ever won”
Same type of story from Breuillet, in Charente-Maritime, which saw its only doctor leave for a neighboring town, located around fifteen kilometers away, in 2021. “She was hired for five years, the town had provided the furniture of the office, the health center had offered her three months of free rent… But she found cheaper rent next door, and left us in the lurch”, says Dany Orion, director of the private health center of the municipality. “It’s competition, there are no other words,” he breathes. In this race for attractiveness, the town hall decided to put up banners at the entrance to the city to try to attract doctors, bought new furniture for the health center and financed a medical secretariat, while Dany Orion offered one year of free office rent to interested GPs, and invested more than 3,000 euros in installing fiber in the premises. “Someone showed up, and hesitated for a long time with another neighboring town which offered two years of free office rent and accommodation provided,” explains the director. The general practitioner finally chose Breuillet last October… before leaving, a few months later, for the public hospital. “Even when you manage to seduce a doctor, he has to deal with the aging population, the appointments that follow one another, life in the countryside… Nothing is ever won,” he regrets.
Faced with a more than tense situation, certain departments have decided to react. In Lot-et-Garonne, the Departmental Council and the local AMR thus unanimously adopted, in February 2021, a charter of reciprocal commitment, aiming “to combat competition between territories in terms of medical demography”. “Unfortunately, the installation incentive strategies taken by local authorities have sometimes turned into overbidding and competition. […]rather than focusing on complementarity or coherence”, lament the elected officials. “Very often, this ‘race forward’ results in phenomena of ‘double punishment’ of the least well-endowed territories, with limited financial means” , they add, encouraging the signatories “not to poach a doctor from a signatory territory”, not to offer “financial advantages to help with the installation”, or even to offer “a salary and a type of identical contracts between municipalities”. “This charter remains symbolic, but everything had to be done to stop the bleeding”, summarizes Guy Clua, vice-president of AMR 47. It was more than time. “We were starting to notice the presence headhunters, recruitment firms or unscrupulous doctors who changed territory every two years to benefit from the advantages”, summarizes the elected official.
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