The map reveals a Hexagon riddled with red and black dots. According to figures from the Samu-Urgences de France organization, at least 120 emergency services are in distress in France for the summer. About one in five establishments hosting an emergency service is forced to reduce its activities due to a lack of caregivers, or even close. Less than two months before the summer holidays, fourteen University Hospitals are concerned, everywhere in France, regardless of the regions or the size of the establishments.
To cope, the president of the French Hospital Federation (FHF), Frédéric Valletoux, asked the government to decide “urgently” to restore “the duty of care of liberal (doctors)”. “No one should be able to opt out unless there is an exemption due to their state of health or age,” he said. A controversial proposal, which led to a strong reaction from the unions of liberal doctors. “Who is already compensating for the management of emergencies and unscheduled care in the territories, if not the liberals?” Asked the National Conference of Regional Unions of Health Professionals in a statement – Liberal doctors. Before relying on a report carried out by the National Council of the Order of Physicians in 2021, which indicates that the Liberals have a “coverage rate of 96% on weekends and public holidays”.
Six to eight million people in a medical desert
This controversy is all the more complex in that to the tension of the hospitals is added that, structural, of the city medicine. “Since the 2000s, we have faced a very strong growth in requests for access to emergencies, in particular for benign illnesses, combined with a reduction in the number of general practitioners who agree to take patients”, notes Jean-Paul Domin , lecturer in economics at the University of Reims Champagne-Ardenne. Throughout the territory, medical deserts linked to the disappearance of general practitioners and specialists are progressing, whether in the countryside, in peri-urban areas, or even in the centers of agglomerations.
Currently, between six and eight million people live in a medical desert, when six million do not even have a doctor. A lack of access to care which explains, at least in part, why nearly 1.6 million people give it up each year, in town and in the countryside. “We wrongly think that medical deserts correspond to population deserts, points out Jean-Paul Hamon, honorary president of the Federation of Doctors of France. This is not the case.” If the lack of doctors first began to be felt massively in rural areas, it is also increasing in the densest regions.
Ile-de-France, the most affected
So much so that Ile-de-France and Center Val-de-Loire are the regions most affected by medical under-density in mainland France, according to a study of the Research, Studies, Evaluation and Statistics Department (DREES). In Ile-de-France, 62.4% of the population is affected by an “insufficient supply of care or by difficulties in accessing care”, noted a ministerial decree published on October 1, 2021. In two years, between 2018 and 2020, the Paris region lost around 2% of its practitioners, i.e. 150 general practitioners.
“This gap is increasing: the situation is deteriorating very quickly, with a care offer that is suffering, because there are more departures than arrivals of practitioners”, indicates Véronique Lucas, director of research at the Institute for Research and documentation in health economics (Irdes). A situation first linked to an increasingly tight numerus clausus in the early 1990s, when medical promotions did not exceed 3,500 students per year. Since 2010, many riflemen trained in the 1970s and 1980s have thus retired. Between 2012 and 2021, the percentage of doctors per inhabitant has thus decreased by 7% in France. “This is also linked to the aging of the population, which requires more and more care and therefore time for care”, continues Véronique Lucas.
Declining access to care
In towns that are gaining inhabitants, the doctors still present are all the more popular than elsewhere. When these territories struggle to attract health professionals, the medical desert only increases as the population increases. “The under-staffing of these territories in practitioners is accentuated due to the increase in the population: the more an area is badly off, the more the situation worsens”, note Julien Mousquès and Guillaume Chevillard, researchers at Irdes . Between 2016 and 2019, access to care fell by 10% in these places, against “just” 4% on the most advantaged side.
The phenomenon does not only concern the Ile-de-France conurbations: when it comes to finding a new general practitioner, the inhabitants of medium-sized towns are particularly struggling. In 2019, a study by UFC-Que-Choisir showed that if the refusal rate is 33% in municipalities with 3,000 inhabitants, and 34% in municipalities with more than 100,000 people, it rises to 52% in cities with 10,000 to 100,000 inhabitants. If the inhabitants of rural and urban areas can suffer from extended appointment times, those in peripheral France sometimes simply do not have access to them. “It is as if the doctors present in rural areas, knowing that users are deprived of an alternative, were more reluctant to refuse patients, analyzed UFC-Que-Choisir. Conversely, in the deserts medium-sized towns, the presence of colleagues, although in insufficient numbers to meet the needs of the population, seems to relieve the practitioners of guilt”.
Frightening shortages
A double penalty that is all the more difficult to fill since, as elsewhere, these cities have difficulty attracting students who have just graduated. “Several factors can explain the factors of disaffection of urban areas, such as the price of land”, continue the researchers. To become more attractive, some cities are deploying seduction strategies: the city of Le Mans, in Sarthe, for example, has decided to take charge of part of the rent for a medical practice after the retirement of one of its doctors. “But not only, they resume. There is also the living environment: what leisure activities are offered? Can the area allow the spouse to find work?”
Some regions combine the difficulties: in Seine-Saint-Denis, for example, territory deserted by general practitioners, SOS Médecins had explained in 2019 to intervene less and less, in particular for reasons of “security”. “These shortage areas can scare practitioners, notes Aude Lecomte-Salmon, doctor of political science, specializing in research into regulating the supply of care in under-resourced areas. They find themselves faced with an elderly population, requiring follow-up for chronic diseases, with a language barrier that is sometimes greater than elsewhere. We find ourselves in places with longer consultation times, which are therefore less profitable”.
So how do you turn the tide? The end of the numerus clausus in 2021 is part of the answer. But its effects will not occur before the generation currently on the benches of the university arrives on the labor market, in the 2030s. According to the demographic projections of the DREES, the number of general practitioners should thus continue to decline until 2026. “The new generations of doctors will not arrive on the ground for a few years, previously explained to L’Express Elisabeth Hubert, former Minister of Public Health and Health Insurance. Until then , we are going to have a very difficult ten years”. In order to arm themselves for the decade to come, several solutions have already been recommended by the executive, such as the development of telemedicine. “But we must not hide the face: it does not replace the physical examination of a doctor”, warns Jean-Paul Hamon.