As part of the Social Security Financing Bill (PLFSS) 2024, the subject of work stoppages is the subject of all attention. While this renewed interest should be an opportunity to better support employees, it is once again only a question of controls and sanctions. We, doctors from all walks of life who are confronted daily with this complex reality in our practices, once again deplore this repressive trend which is a real misunderstanding and will not solve anything.
Instead, we recommend providing the means for occupational health services to be able to carry out the visits essential for the safety of workers, to develop real systems to help with the professional reintegration of patients on long-term leave, to raise awareness among companies of the impact of working conditions on health and support them in this direction… It is urgent to build adapted solutions, taking into account the health of workers in a global manner.
The social security financing bill (PLFSS) for 2024 demonstrates a desire to reduce expenses linked to daily allowances. A supposed “explosion” of this spending would be the main threat to the sustainability of our social protection model. It should be noted that the growth in daily allowances (+ 3.8% per year on average between 2010 and 2022, to be weighted with the massive increase in 2020 linked to the health crisis) is largely explained by demographic factors such as the increase of the active population and the increase in the retirement age, as well as by the increase in the amount of daily allowances corresponding to the increase in certain salaries. The increase in the rate of use of daily allowances explains only 14% of this growth.
Regarding the reasons for arrests, note that 17.4% of the reasons reported in 2022 had a link with mental health, representing an increase of 125,423 additional arrests for depressive syndrome between 2021 and 2022. This is not surprising in a context of increased frequency of psychological pathologies following the health crisis (13.3% depressive episodes in France in 2021 compared to 9.8% in 2017). While we can welcome the increase in the use of therapeutic part-time work since last year, a system aimed at facilitating professional reintegration, we note that the French system has a much less developed professional reintegration policy than certain European neighbors.
“Making the opinion of the medical examiner mandated by the employer take priority seems to us to be detrimental for the patient”
We could therefore imagine that the social security financing bill for 2024 includes measures aimed at improving working conditions and professional reintegration. This is not the case… On the contrary, the PLFSS 2024 only proposes measures to combat fraud, the implementation of which will most certainly be detrimental both for patients and for our health system. Indeed, article 27 introduces the possibility that daily allowances may be suspended automatically following the decision of a medical inspector mandated by the employer, if the judgment does not seem justified. The measure goes so far as to introduce the possibility of claiming from the patient for reimbursement of daily allowances considered undue!
Until now, in the event of work stoppage considered unjustified by the medical inspector, the Health Insurance medical service had to systematically render a decision so that daily allowances could possibly be suspended. This modification of the procedure, which consists of giving priority to the opinion of the examining doctor mandated by the employer over that of the prescribing doctor without arbitration from Health Insurance, seems to us to be detrimental for the patient. While an appeal is still possible, it will inevitably take time. During this period, the person will be deprived of resources, leading to a significant risk of job insecurity despite the inability to return to work. Furthermore, it is difficult to know what legitimacy these examining doctors have to override the advice of the prescribing doctor. How can we not fear conflicts of interest as well as the risk of privatization of these controls, as user representatives point out?
Considering the increase in daily allowance expenses only through the prism of fraud is to ignore the issues linked to working conditions and arduousness. Wanting to punish by excessively strengthening controls will solve neither the problems linked to the deterioration of working conditions, nor those linked to the increase in the average age of workers. DARES (directorate for the animation of research, studies and statistics, an organization of the Ministry of Labor) reported in 2021 a decrease in occupational health visits: in 2019 39% of private sector employees reported a visit to occupational health services in the last 12 months compared to 70% in 2005. It is urgent to provide the means to occupational health services to carry out the medical examinations and site visits essential to guarantee the safety of workers.
The ravages of presenteeism
It is also essential to develop real professional reintegration support systems to support patients on long-term leave. General practitioners too often find themselves alone and helpless to guide patients in these situations. To reduce the use of work stoppages, companies must become aware of the impact of working conditions on health. Regular checks of the state of physical and psychological health, implementation and systematic evaluations of safety measures by field workers, regular training, adaptation of management methods to take into account well-being at work are all essential elements to guarantee the health of workers.
Studies also look at the prevalence of presenteeism and its effects on health. This is about going to work while sick. This can for example apply to infectious diseases with the risk of contamination of colleagues, or to psychological pathologies such as an early anxiety-depressive syndrome, for which a one-off work stoppage can be part of the therapeutic arsenal. The causes of presenteeism are multiple: fear of loss of remuneration, desire not to leave colleagues in difficulty or having too heavy a workload upon return (especially if it is impossible to be replaced), fear of being stigmatized or sidelined. In 2019, the Malakoff Humanis barometer estimated the number of unused sick leave at 28% (9 points more than in 2016). It seems to us that a repressive attitude is likely to encourage this presenteeism and therefore increase the risks for workers’ health.
We easily agree that work stoppages should always be as short as possible. But rather than resorting to control and repression, we plead for global consideration of the health of workers, with particular attention paid to preserving it, through appropriate monitoring, improving working conditions, assistance with any form of socio-professional reintegration when necessary. Let’s build together solutions adapted to the complex realities that we encounter every day in our practices.
Dr Sophie BAUER, president of the Union of Liberal Doctors (SML)
Dr Raphaël DACHICOURT, president of the Autonomous Grouping of Young Established and Replacement General Practitioners (ReAGJIR)
Dr Franck DEVULDER, president of the Confederation of French Medical Unions (CSMF)
Professor Paul FRAPPE, president of the College of General Medicine
Dr Agnès GIANNOTTI, president of the MG France union
Dr Patricia LEFEBURE, president of the Federation of Doctors of France (FMD)
Dr Jérôme MARTY, president of the French Union for Free Medicine (UFML)