Health‐care system in France

Abstract

The French health-care system is almost totally under the supervision of the government, which defines the general orientation of health policy. For example, a health-care policy for cancer treatment will be developed in France within the next 5 years. The government organizes the initial formation of all categories of health professionals and so controls the number of professionals in each category. In France, 4500 medical students graduate each year. Demographic problems at the present time are caused by the quota for all medical professions. The government also ensures that the number and location of hospitals are adequate for the needs of the French population. It supervises public hospitals and the management of private clinics, with the objective of providing a consistent standard of care in all health-care structures. The government also proposes the health budget for parliament's approval. In 1996, in line with the concept of decentralization, which means ‘to think globally but act locally’, regional agencies for hospital care were created in each administrative region. They are responsible for the strategic and economic supervision of hospitals, and for the organization of regional health care. However, they have no authority with regard to ambulatory care, thus creating a gap between hospital and ambulatory care in France, which represents a great obstacle to the coordination of care for disabled and elderly people. The French health-care system is a mixed system, being both etatic and liberal. There is a collective health insurance program in place based on incomes; the premium payments are automatically deducted from salaries. The rate is determined each year by the government for an equilibrated budget. Patients have completely free access to all medical care, including hospitals and choice of practitioners. They can have as many consultations and hospitalizations as they want. Furthermore, public and private health structures coexist. Sixty-five percent of hospitals are public and 35% are private. Ambulatory care structures are mainly private (95%). Therefore, although the French system is complex, comprising etatic and private organizations, it functions well. Furthermore, freedom and heterogeneity are probably the main guarantees of quality of health care in France, even if the cost is high and constantly increasing. In France, the number of available hospital beds for acute care (short-stay units), rehabilitation, long-term care and psychiatry is high (Table 1). The rates per 1000 people are the highest in Europe. However, the number of beds for disabled geriatric patients is low: 400 000 beds in retirement homes and 68 000 beds in long-term care units. There is a very long queue to get into such establishments. For psychiatric institutions, there are a total of 6430 beds. The number of health professionals is quite high (Table 2), but they are growing older and demographic problems will arise in the next 10 years. To finance the health-care system, including ambulatory and hospital care, a budget is approved by parliament annually. Ten percent of the gross domestic product (GDP) is devoted to the health-care system (130bn euros), including public hospitals, private hospitals, ambulatory care organizations and pharmacies (Table 3). The budget is being constantly increased. Patients can get a refund of the total cost of health care. For example, refunds for hospitalization costs are between 80% and 100%. For ambulatory care, refunds are between 70% and 100% and for drugs, between 35% and 100%. Health care is free for the homeless and poor people (100% refund). There is a list of 30 severe diseases, including Alzheimer's disease (AD), for which patients are entitled to a 100% refund. Last year, the treatment of AD was listed as a national priority and the government established a care program for the disease. Two main initiatives were proposed. The first one is diagnosis, particularly early diagnosis, as only half of the patients are diagnosed in France. In regard to this, the program proposed the development of memory clinics and regional expert centers. The second initiative is to provide better care for people with AD. This covers ethical issues, the possibility of family caregivers benefiting from some help, financial aid, and the creation of social day-care centers. Hospital care for people with AD is totally paid for by the social security system. Various options are available: short-stay units, rehabilitation units, and day hospitals (of which there are too few) for diagnosis and rehabilitation. Furthermore, people with AD are generally not very welcome in traditional short-stay and rehabilitation units, and it is very difficult to get them a place in such units. Memory clinics are being developed and regional expert centers will be created next year to assist in the early diagnosis of the disease. An expert center must meet specific defined criteria. It must have a multidisciplinary team (neurologists, geriatricians, psychiatrists, and neuropsychologists) and a day hospital for disease diagnosis (capable of handling at least 100 new patients a year). It must also be a source of expertise in research, possess postgraduate knowledge about dementia, and be the centre of a network including general practitioners, ambulatory neurologists and memory clinics of the first degree. Ambulatory care for people with AD is provided by neurologists and psychiatrists (both in insufficient numbers), and by general practitioners, who are not accurately trained for dementia care. Very few geriatricians are included in ambulatory care. Nurses, orthophonists, and physiotherapists are also involved, but again, they are insufficient in number. In other words, social day-care centers should be developed. Social support for patients is financed by a new prestation, the ‘APA’ (personalized prestation for the promotion of autonomy). This prestation was defined in 2002. The amount of the prestation is calculated according to the loss of autonomy. Patients are classified into six groups upon evaluation of their autonomy. It is possible for patients to buy the time of professional social workers and caregivers. The highest level of financial aid they can obtain is 1200 euros per month. Today, 50% of patients are being looked after only by family caregivers. Nursing homes are currently evolving in France. Retirement homes and long-term care units now belong to a single category. The total living expenses comprise three parts: food and housing costs are borne by the patients (through family or social aid); nursing costs are covered by the APA prestation and patients (or their families); and the total cost of medical care is covered by social security (100%). In conclusion, the French health-care system is quite unique since it involves both etatic and liberal organizations. It is an excellent system for patients because of low medical costs, but it requires a high cost of maintenance.