Eleven billion euros is the deficit in the health branch of social security. Two billion euros is the estimated deficit of public hospitals in 2024. It was “only” 569 million in 2019 before Covid and 1 billion in 2022. The pandemic, the necessary salary increases, the evolution of activities (and yes, the day hospital is less profitable than full hospitalization), inflation, the price of energy, renovations are a burden that the public hospital, helped after Covid and Ségur de la santé, now supports it alone without its funding having changed.
Beyond its specific technical missions of specialized consultations and hospitalization, the public hospital remains a daily recourse in an environment where the city medical fabric is becoming rarer and where the strategy of private establishments, in any case very much in the minority, is also to survive. It is essential in the event of a crisis, as we saw with Covid or other major events such as the Olympic Games, without anyone wondering if they are able to respond or wondering about the impact of these events on this already weakened system. He must answer.
It is unlikely that the new Minister of Health’s first decision will be to fill the hospital deficit. It is also unlikely that in this context, hospitals will be able to strengthen their medical or paramedical attractiveness. The time for Covid aid and “whatever it takes” is now over.
We can lament, continue to demand more staff, without changing anything in our organization as the inter-emergency and inter-hospital collectives, ultra-left unions and medical professors did before 2020. Change everything so that nothing changes, especially not privileges.
Lack of evaluation
It is quite symptomatic to see that the Prime Minister’s first visit was made to a Samu, repeating almost all the first visits by Ministers of Health or directors of ARS. This structure that “the world envies us” is a French exception. Each local elected official is ready to sacrifice their emergency service which treats tens of thousands of patients each year to keep these SMURs which will at best see a thousand to two thousand. For what ? Because “it saves lives”, we are told. What do we really know about it? Is it more effective than the Anglo-Saxon systems without a doctor? This has in reality never been evaluated, which is symptomatic of our system: the measures taken are intended for politics and are very rarely evaluated.
In the city, can we also continue to leave medical deserts without a doctor, with degraded teleconsultation medicine as access to care, or overloaded emergency services – when they are not filtered or completely closed, a situation of which we know What is one of the explanations for the far-right vote?
Either way, we all know we won’t have more money. We therefore find ourselves at the back of the wall and we no longer have a choice. Either we are moving towards a progressive disintegration of the system as it exists today, with access for all, towards ultimately a two-speed medicine. We see this with the systematic excesses of fees in certain regions, even the choice made by certain doctors to withdraw from the convention (Editor’s note: doctors who have withdrawn from the convention are free from their prices and their consultations are no longer reimbursed). Either we reform or rather we revolutionize the system to maintain and strengthen access to quality care for all.
Administrative surplus
Current health system reforms rely on financial incentives or limitations on reimbursement to “care producers,” with policies carefully avoiding appearing to limit access to care for patients, who remain voters. A recent example is the reform of emergency financing based on a combination of packages that do not cover costs, an allocation to the hand of the ARS, and a small part on “quality”, quality based in part on the passage times of the elderly people whose responsibility rests on the functioning of the hospital and not on the structures put in place upon discharge from this hospital.
Leaving the hospital is also one of the blind spots when we talk about hospital dysfunctions. Everyone complains about the lack of beds. According to commentators, it is the fault of the government, of the hospitals themselves which are not hiring, or of the staff who are reluctant to take on the task. No one mentions the fact that if much less expensive arrangements for discharge to home or to an institution were put in place, some of the bed problems would be resolved.
The administrative surplus is frequently highlighted. But what do these administrators do? They respond to increasingly onerous regulations or to requests for indicators that go in all directions, coming from the entire technocratic hierarchy going back to the minister, each adding their own little request. At the hospital level, a technocrat is in charge. As good as his training is, it is also a French exception that it is not a health professional who runs the hospital, the director in this case being the general secretary.
Flight of staff
Hospital recruitment is problematic and very expensive, while never aligning with the remuneration or quality of life that healthcare professionals can find elsewhere. Under these conditions, not only are we no longer attracting young people who would like to train in paramedical professions, but we are also leading to a flight of medical personnel towards more remunerative and often less interesting professions. Those who stay are therefore never evaluated on their productivity for fear that they too will jump ship.
The hospital only relies on the goodwill of a few who are exhausted. Paradoxically, if we want to save money we will have to seek medical and administrative excellence. Yes, we should reduce hospital bureaucracy and its silo organization. But it also means restoring real autonomy to establishments and functioning more in line with hospital needs and an organization truly centered on the patient with effective management.
Medical corporatism is a blight on our health system. The doctor is at the center of everything. Other healthcare professionals are considered auxiliaries unlike in foreign countries, without decision-making power, without their own responsibilities in care – except in the event of an error. We have seen the reception by nurses of advanced practices by liberal unions and especially by the council of the order, guardian of the temple of an aging corporatism. We also know the reactions of this same medical profession when pharmacists were asked to vaccinate.
For our system to survive, we will also have to empower patients. The most liberal want a remainder to be imposed on the sick. This is typically a false good idea leading the poorest not to seek treatment and ultimately to cost more (let’s not talk about ethics). But expecting the system to immediately respond to all requests, regardless of severity, while being 100% reliable, is impossible. Health is a right, deciding the terms of recourse yourself is not. It is no longer possible to allow the patient to seek the care they think is necessary. The channels and directions (such as those recommended in the event of a call to the access to care service, the SAS or to the emergency reception) must be respected. The right prescription must be imposed.
All this will require political courage which it would be naive to expect. Ministers of Health, generally politically weak, succeed one another at a greater rate than that of our interns. It is time to create an agency independent of the overhaul of the system, with experienced health professionals and administrators, and not yet another bureaucratic structure consuming time and money. It will have to make proposals from the professionals themselves, with administrators and health insurance, responsible for public health and care. Our system is in a vital emergency. It’s time to act.
* Mathias Wargon is head of the emergency and Smur department in Seine-Saint-Denis