He never minces his words and rarely hesitates to denounce what he knows to be false and what he considers unfair or stupid. With, most often, a flowery language that he assumes – and which contrasts with the cautious speeches and the language of wood of others. Mathias Wargon, head of the emergency department and the SMUR of the Delafontaine hospital in Saint-Denis (Seine-Saint-Denis), is no exception to his habits when it comes to returning to the statements of Emmanuel Macron who has promised, during a televised address on Monday April 17, to “unclog” the emergency services by the end of 2024.
L’Express: What did you think when you heard the president’s speech on Monday evening?
Mathias Wargon: I was surprised and amazed, especially since Emmanuel Macron did not present the beginning of a solution. The problem of emergencies cannot be divorced from that of the French hospital system in general. Settling all this in a year and a half is a short time. And even if we could solve the problem of emergencies separately, that would still be short, because we have to rethink them, rebuild them entirely. We have to deal with a lack of medical and paramedical personnel, who no longer come, in particular because the emergency rooms are overloaded with an ever-increasing number of patients. All the public services in my department are registering 4000 to 5000 more passages compared to 2019, and this figure is increasing every year.
There you summarize the two problems of emergencies. The lack of care upstream, before arriving at the emergency room; and that downstream, linked to the failure of emergency reception capacities. What are these two phenomena due to?
The upstream problem is related to the fact that city medicine is not sufficiently supplied. There is a lack of supply of general practitioners. And those who are there can no longer take more patients. On the other hand, when it was proposed that APIs [infirmiers en pratique avancée, qui possèdent un master spécifique et trois ans de terrain minimum, NDLR] and physiotherapists can take care of certain patients without medical supervision, some of the doctors refused. And the government gave in to corporatism. We cannot oppose treatment by IPAs and physiotherapists and say that we cannot take on more patients. As for the idea of increasing the doctors who agree to receive more patients by opening late or on weekends, this is not a solution but slaughter, which goes against good medicine. .
The second problem is that of filtering, since emergencies end up with patients who have nothing to do there. Emergency rooms should be easy to access for serious or potentially serious patients, and difficult to access for others. The experimentation of the Care Access Service (SAS) [qui permet d’orienter les patients confrontés à un besoin qu’ils estiment urgent grâce à une téléconsultation avec un professionnel de santé, NDLR] works quite well, although it tends to pick up resources that could be attributed to emergency medicine. Another problem with the SAS is that it must offer solutions to patients, otherwise ethical issues arise. And then, I’m sorry, but for a patient we don’t know, teleconsultation is not a panacea, it’s not good medicine. Anyway, this device is not in place in all regions and it will probably not be present everywhere by the end of 2024.
And downstream, how to explain the failures of emergencies?
The problem of hospitals is that they sometimes cannot hospitalize for lack of beds. Some are closed for lack of staff, doctors, paramedics, etc. There is a big problem with the attractiveness of hospitals and emergencies, because the working conditions are bad, the salaries are not attractive and there is a lack of empathy and recognition from the administration. And there are also some beds blocked by patients who have nothing to do there, because they should be at home, or in follow-up care, or in structures that can keep them, such as medical establishments. -social, medicalized retirement homes, specialized homes… I am thinking, for example, of young patients who suffer from neuro-cognitive diseases that we are unable to place. Some sometimes stay a year in the hospital. A patient who stays a year in a bed takes the place of 52 patients who stay a week.
Why can’t these problems be solved by the end of 2024?
Because we need to carry out a fundamental overhaul of the health system. I don’t think it’s possible to renovate it in such a short time. And I’m worried because it’s urgent. The hospital held up last summer because a lot of money was injected: we paid more for temporary workers, we increased the price of on-call doctors, but these are not long-lasting solutions. Today, in Ile-de-France alone, several services are in crisis. Bry-sur-Marne hospital closed its emergency department for a week, and this is a hospital located 10 kilometers from Paris, so not exactly in the middle of nowhere. The Foch hospital, in Suresnes, (Hauts-de-Seine) and that of Aulnay, in Seine-Saint-Denis, are also in difficulty and close their emergencies regularly. I too hope that the emergency services will be relieved one day, but November 2024 seems a little bit ambitious to me.
What would be the ideal solutions to put in place quickly?
But there is no ideal solution! The solution is to rethink the entire health system. City medicine must be reorganized so that emergencies no longer become the only solution. It is therefore necessary to review the city offer and, probably, the pricing of general practitioners. We must make working conditions more attractive, question the organization of the maintenance of home care…
Same thing at the hospital, where you have to review what it means to be a doctor, with a little more consideration, because when you find yourself on a field of ruin after the Covid, waiting for thanks, and that we are told “get out of our way”, it’s complicated… In short, you have to carry out real in-depth work. And all this will not happen in 20 months, even if I would like to believe it. To unclog the emergencies so quickly, apart from blocking the entrance, I don’t see.