French healthcare: the high cost of excellenceBMJ 2011; 342 doi: http://dx.doi.org/10.1136/bmj.d1524 (Published 15 March 2011) Cite this as: BMJ 2011;342:d1524
The Georges Pompidou European Hospital is a gleaming example of a modern French university hospital. When you arrive it feels as though you have come to a plush shopping centre or an airport (it was designed by leading French architect Aymeric Zublena, who also co-designed the Stade de France football stadium). Beneath a high, modern glass and steel structure, there is a central “street” where patients, students, doctors, and the public mingle in a light, airy setting complete with palm tree, cacti, and a film centre. Off one side there is a newsagent, a café, and a panoramic lift leading to spacious offices flooded with natural light. To the other side are the wards, where nurses push computers on trolleys down wide corridors with brushed steel hand rails and metal splash protectors along the walls. Ninety per cent of patients have their own room with en suite bathroom, and some have a sofa bed for relatives wishing to stay the night. There are large, well equipped operating theatres and a digitised drugs dispensing system that allows hospital staff to withdraw stock by tapping the name and quantity into a screen and automatically orders new stocks when supplies run low.
Built just over 10 years ago, it is a model of modern French hospital management. It replaced five old institutions and groups together three hospitals, coordinating the resources, facilities, and expertise of each to provide efficient, top quality care for the 600 000 residents of south western Paris. The hospital opened in 2000, the same year that the World Health Organization announced that France had the best health system in the world.1
The only problem is that the hospital overspends every year. The deficit was €25m (£22m; $35m) in 2009, the latest year for which figures are available.
Like this hospital, the entire French health system has a reputation for high standards of care and facilities. But today the state health insurance fund is €14.5bn in the red—and a climate that once tolerated living beyond your means has suddenly gone.
France is scrambling to get its public books in order to avoid having its credit rating downgraded. And health spending now accounts for more than half of the total social security overspend. But when it comes to health, public opinion is so strongly against any major changes, that all that Nicolas Sarkozy’s government has been able to do is nibble at the edges of the deficit problem.
“I fear we are heading for a catastrophe. I am not optimistic,” says Philippe Even, a medical adviser to the French health minister and president of Necker, a Paris health research institute.
France faces similar problems to many industrialised countries in that it is trying to control health spending at a time when its population is ageing, there is a shortage of medical staff, and costs keep rising for sophisticated equipment and treatments.
The French case is particularly acute. French women are now living longer than any in Europe (84.4 years), and if they make it to 65, the French then live longer than any of their European counterparts (women 22.6 years, men 18.1 years).2 And because of a cut back on medical training and the retirement of the babyboom generation, the number of general practitioners in France is expected to drop from 54 000 in 2010 to 27 000 in 2020, according to figures from MG France, the general practitioners’ union.
The French system also has some idiosyncracies that add to the problem. Professor Even, like many others, points to a culture of waste and unnecessary use of health services. In the name of high standards of healthcare, he explains, French hospitals have got into the habit of carrying out unnecessary procedures, prescribing unnecessary drugs, and “ticking the boxes for all sorts of tests to be done” rather than targeting the most likely causes of complaints. Patients stay in hospital for longer than in many other countries (average length of stay in a French hospital is 13 days, compared with eight in the UK and five in Denmark3) and are often transported in ambulances when a taxi would suffice, he says.
“Hospitals act as if money doesn’t matter,” Professor Even tells me. “Staff spend without thinking about what they’re spending.”
The public have come to expect this level of care and attention and governments find it hard to trim anything back without facing public unrest. At present, France can be proud to be the country where you are least likely to die if you contract a preventable disease.3 But at the same time, observers say, France is running a health service that many treat like an open bar. France is one of the world’s biggest consumers of drugs (in 2008 it spent more on drugs than all other countries in the Organisation for Economic Cooperation and Development (OECD) except the United States, Canada, and Ireland and almost twice as much as the UK4). France consumes more antibiotics than any country in the OECD except Greece,5 and of the 4000 drugs currently on the French market, Professor Even believes as many as half are not proven to have any medical value. Eliminating prescription of useless medicines and overuse of effective drugs and limiting access to the most expensive new cancer treatments would save up to €10bn a year, Professor Even estimates. That is a third of the total annual drug spend. Other estimates say the saving could be closer to €5bn, but there are no official government calculations.
The government has begun to tackle this and other kinds of waste. It is gradually withdrawing certain drugs from the list of those that the state will pay for. Decisions about which drugs should be withdrawn and reimbursement of new drugs are made by the Agence de Produits de Santé en France. When drugs are considered not really useful, it decides to reimburse a small percentage of its costs or none at all. Critics say it should be braver and just declare more of them useless or unfeasibly expensive. There have also been attempts to change public attitudes through government publicity campaigns reminding people that “antibiotics are not automatic.” Ironically, it may ultimately be scandals over the health risks of some unsuitably prescribed drugs (like Servier’s Mediator (benfluorex), which is thought to have caused between 500 and 2000 deaths after being widely used as a weight loss pill rather than for its licensed purpose) that may lead the French to be more cautious about popping so many pills.
Jann Bubien, counsellor to the health minister in charge of hospitals, care provision, and social relations, insists the government will tackle problems like unnecessary consultations and operations such as removing appendixes, which occur two to three times more often in France than elsewhere. But, he says, it’s hard to define which procedures really are unnecessary.
Many see any attempt to reduce the amount of operations, tests, or medicines provided as an attack on the quality of the service. And any substantial cuts aimed at greater efficiency and less waste would imply job losses in the health sector, which is one of the largest employers in France. The drug industry is also a leading employer and currently one of the few thriving sectors of the economy.
“There is no miracle method for resolving the deficit problem,” says Mr Bubien. “There is no question of introducing drastic measures that would involve job losses. We have constantly to improve things bit by bit.”
The government has given state hospitals five years (ending at the end of 2012) to balance their books, and hospitals are cutting back on everything from numbers of beds to quality of food. According to Mr Bubien, the total overspend has already dropped from €900m to €500m. He expects it to fall by at least another €100m this year.
A law was passed in 2009 aimed at improving efficiency in hospital management and consolidating resources. And a digital medical record system, on trial in several regions, has the potential to identify duplication of effort and help doctors make better informed decisions about patients.
But with general elections in April 2012, the government is unlikely to attempt any major health reforms before then.
“We can’t say that we have made drastic savings,” says Mr Bubien. “Nobody is asking us to. In France, health is sacred; the system is sacred. It’s one of the hardest things to touch.”
Whoever is elected next year faces a huge challenge as demands on the health service grow. France needs to keep increasing health spending to keep up with those demands, but it already spends a larger proportion of its gross domestic product (GDP) on health than any other country in Europe (11.2% compared with 8.6% in the UK and 10.5% in Germany).4
And now, as the global economic crisis has pushed unemployment up, social security contributions, which are calculated according to earnings, have dropped dramatically. The deficit of the national insurance fund for healthcare (known as Assurance Maladie) jumped to €14.5bn in 2010 from €4.5bn in 2008.6
That is more than half of the total social security deficit (covering pensions and social benefits as well as healthcare), which was €23bn in 2010. The government is under pressure to cut its public deficit from the current 6% of GDP to 3% by 2012 or risk being downgraded in international credit rankings.
Successive governments have recognised that the health system is in need of reform, but when they attempt to introduce major changes, public outcry forces them into retreat.
France’s ultra-liberal health system, based on the principle that patients should have access to any doctor or specialist or hospital they want, means the public are very content. People can choose to see a specialist or a general practitioner as often as they feel necessary and whether to be treated in a state, private, or non-profit (usually run by religious orders) hospital (about 60% of hospitals are state run). All those earning more than the minimum wage pay contributions to the health fund and therefore feel entitled to the choice the system provides.
The universal coverage system means patients must pay up front for services and will then be reimbursed the majority of the costs (the proportion varies depending on the service) by the state health system. Over 90% of the population has a top-up insurance policy that covers the remainder or almost all of it. For fundamental services such as maternity care or treatment for acute and long term illnesses the state covers all costs.
At present, the average time a woman spends in hospital after giving birth is four to five days. The pulse of the baby is monitored electronically throughout the birth and epidurals are the norm. Mothers receive thorough training in child care before going home. The state will cover the full cost for a stay in a room shared with one other person. The only thing the woman has to pay for out of her own pocket is the use of a telephone and television while in hospital (€10 a day). She can choose to pay a supplement of €53 a day for a single room, which her top-up insurance policy may cover. Many women choose to give birth in a private clinic to be guaranteed a single room (often with a spare bed for the father). The total cost can be around €1000 for the full stay and the Assurance Maladie and a top-up insurance policy combined will cover about 85% of the cost.
As the pressure has grown on finances, the government has begun to pass some costs on to the public or insurers. A law passed in 2004 attempted to establish a general practitioner gatekeeper system, much like that in the UK. Patients who go directly to a specialist without being referred by a general practitioner are reimbursed a little less by the state. The government has also introduced patient charges of €1 for each consultation and €12 for every day spent in hospital. New health conditions have been added to the list of those not covered or covered at a lower percentage by the health insurance fund.
Many of the top-up insurance policies are picking up these costs, with the result that premiums—though still modest—are rising. And this has led to concerns that the French system is losing its fundamental principle of solidarity.
“Increasingly health is paid for by the sick rather than by general contributions,” Zeynep Or, a researcher at the Institut de Recherche et Documentation en Economie de la Sante (an independent health research institute), concluded in a review of the 2011 health budget.6
“The budget project falls short of addressing any of the major efficiency issue and does not propose any useful measures for altering health care provision and consumption patterns,” Or says.
Role of general practice
Many health professionals believe that deeper restructuring and reorganising of the French system is the only thing that can alter the trend of overspending. The general practitioners believe shifting the emphasis away from state hospital care (which is reimbursed at close to 90%) to primary care (which is currently reimbursed at closer to 50% by the state) is the answer. Others think that the answer is to impose limits on the way all health providers work.
Under the current system, general practitioners and specialists working outside hospitals are self employed. They can work anywhere they choose in the country. When the government has attempted to set limits in an attempt to gain a better distribution nationwide, health professionals have been up in arms.
Cities tend to be full of doctors of all sorts and small towns and rural areas very under served. And there are roughly as many specialists operating independently (and competing with each other for patients) as there are general practitioners.
Although the gatekeeper system has begun to show savings, MG France, the general practitioners’ union, says that it has not significantly changed attitudes.
“All that happens is that patients demand signed referrals [from us] and we have to fill out more forms,” says Jacques Battistoni, general secretary of MG France.
General practitioners are among the least well paid in Europe and are allowed to charge a set fee of only €23 per consultation. After covering their office running costs and paying social security this leaves them with €7 take-home pay per consultation, according to the union. The result is that many cannot afford to risk losing a patient by refusing them the prescription or the referral that they want.
The union believes that the fact that general practitioner services are so cheap, may eventually lead the government to make more use of primary care. “As long as the choice is not structured to a minimum, we will not get out of this [situation],” said Francois Wilthien, vice president of the union and a practising general practitioner for 35 years.
However, in coming years there will be fewer and fewer doctors per capita as a post war generation go into retirement and quotas set years back mean that there are now not enough new doctors qualifying. Many fear that there will be a crisis in the next few years.
“In concrete terms, patients are going to have to travel further to get care. Small towns may not have many GPs or other types of care. There will be uprisings in the regions over health,” says Dr Wilthien.
If the government does not tackle the need to reorganise the system, he believes, “the fabric of French health will disintegrate.” After the 2012 elections, whoever is in government will need to make difficult decisions. There will be brutal closing down of all sorts of services. “We will no longer be the champions of the world in terms of access to services.”
Jean Yves Fagon, a professor of medicine at the University of Paris Decartes and former director of medical affairs and strategy for Paris hospitals (Assistance Publique, Hopitaux de Paris), believes that the incremental cuts being made in hospitals mean that France has already lost that status. “The quality of services are being gradually degraded to cut deficits now,” he says. “But there is no long term strategy.”
“We needed to reorganise the whole system of healthcare provision. We didn’t do it when we had plenty of money. And now it will be much harder to do.”
Cite this as: BMJ 2011;342:d1524
Competing interests: The author has completed the unified competing interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.