France's next president faces tough decisions on health

Whoever wins France's presidential election in May will have to tackle some difficult problems in the country's efficient but hugely expensive health system. Kim Willsher reports from Paris.

In a drop-in clinic in a raggle-taggle area of north Paris, half a dozen mothers are waiting to have their babies weighed and measured or their toddlers vaccinated. The large, bright waiting room is decorated with drawings and colourful posters and filled with toys being energetically employed by a group of infants. A doctor is doing health checks and jabs, while other staff are on hand to give advice and support to mothers who feel isolated or depressed or simply need help with the multitude of anxieties facing new parents. Many of the women they see are poor; some are immigrants with a tenuous grasp of French; others are middle-class parents seeking reassurance. All get the same consideration and care, and the treatment is free.

The French maternal and child protection system, known as PMI, began in 1945 with the principal aim of ensuring each child, whatever their social background, was given as healthy a start in life as possible. Today it is just one of the many pieces of the jigsaw that is the French health system; a system consistently declared one of the best and most generous in the world.

It is a system that has helped give the French life expectancy of an average of 81 years, infant mortality rates of 3•9 per 1000 livebirths, and 3•3 doctors per 1000 population, according to the latest figures available from the Organisation for Economic Cooperation and Development (OECD). It is, however, hugely expensive. Now doomsayers warn that unless France gets to grips with runaway health spending it is heading for disaster.

Philippe Even, an adviser to the French health ministry, and president of the Institute Necker, a Paris-based think tank and funding institute tied to the Necker Medical School is a fierce critic of the French health system that he describes as “exorbitantly expensive and utterly wasteful”, and requiring structural reform.

His diagnosis is damning: hospitals do too many unnecessary operations, procedures, scans, and tests; doctors prescribe too many inefficient or useless at best, dangerous at worst, drugs; and the system is heading for a catastrophe.

“Studies have shown that 30% of operations in French hospitals serve no purpose whatsoever, people stay in hospital far too long, and there is a gulf between the prevalence of high-tech equipment and the availability of personnel qualified to use it. Doctors are also performing unnecessary tests to cover everything…because they fear being sued”, Even told The Lancet.

France spends 11•8% of its GDP on health, the third highest in the world behind the USA and the Netherlands, which adds up to US$3978 (around €2985) per person, according to the OECD. With the onset of the global economic crisis, pressure was already on the French authorities to wrestle with public spending to get its budget deficit back on track. Today with the loss of the country's AAA credit rating, and with the state health fund, the Assurance Maladie, €14•5 billion in the red, the need for belt-tightening has become even more imperative. Although everybody agrees the French health system cannot go on living beyond its means, nobody has come up with a magic solution to cut costs without also hampering the quality and depth of services.

Certainly there will be no major initiatives for the next few months as France goes through first presidential, then legislative elections. In fact, in the mistral of daily, sometimes hourly, declarations, pronouncements and press releases from the ten presidential candidates running for election in the two-round vote in April and May, health reform is conspicuously absent. “The politicians are scared by the health issue. It's too much of a minefield. Nobody dares address the problems because they fear losing 100 000 votes in one fell swoop”, Louis-Jean Couderc, head of the Respiratory Diseases department at the Hospital Foch at Suresnes just outside Paris, said.

Jean de Kervasdoué, a health economist and former director general of hospitals, agreed: “Not one of the candidates is speaking about health. I don't think any one of them has a clue how to fill the big hole in the health budget.”

“The problem in France is that we don't face up to resolving problems until they become dramatic, and the question of France's health system is going to become dramatic in the next 18 months. Then we will all have a very big headache.”

It would take a brave person to address the problems right now, but governments have tried in the past, and largely failed. Nicolas Sarkozy came to power in 2007 with promises of reform, but has only been able to tinker with the system for fear of protests. Public opinion is vehemently against changes that might erode people's access to health care or the quality of treatment and the freedom to choose who delivers it. Doctors are also opposed to changes that infringe their independence.

Socialist presidential candidate Françoise Hollande has vowed to cut health costs

Patients pay up front for services and, with a few exceptions, are reimbursed most of the costs by the state. Around 90% of people have a top-up insurance policy that covers what the state does not reimburse. Treatment for acute and long-term illnesses are reimbursed at 100%. In 2009, Businessweek magazine wrote: “to grasp how the French system works, think about Medicare in the US then expand that to encompass the entire population.”

Sarkozy's government has tried to bring down spending, making patients go to a referring doctor—the equivalent of registering with a general practitioner—if they wish to seek specialist treatment and have it fully reimbursed. Before they could see any doctor or specialist—or several of each—they wanted. A charge of €1 for each medical appointment was levied on all but the poorest patients and certain generic drugs have been withdrawn from the list of those that the state will reimburse, combined with widespread campaigns to halt the overprescription of antibiotics. There has also been a reorganisation of state hospitals, which are under orders to balance their books before the end of this year.

Couderc said the hospital reform had “seemed like a good idea”, but had introduced a new level of bureaucracy that had “paralysed” the decision-making process and consequently their development. “Also, the administration is no longer medical it's financial. You want to try something new medically, and you are asked for a business plan. That's not medicine, that's money.”

Whoever is elected in May faces some hard decisions. On one hand the demands on the health service are growing with, like many other countries, an ageing population, more expensive treatments and procedures, and a large number of doctors reaching retirement age and not being replaced. On the other, income is shrinking since social security contributions, calculated on earnings, have been hit by rising unemployment.

Health spending accounts for around half the €23 billion Sécurité Sociale debt (the other parts being pensions and family allowances). In October, 2011, the French Government announced a second austerity plan to reduce spending growth from 2•8% to 2•5% yearly, saving €2•7 billion each year.

Many health experts and those working in the system say it needs reorganising and restructuring to reduce waste and inefficiency. “France always chooses the most expensive. We choose expensive hospitals over less expensive clinics, expensive specialists over less expensive general doctors, expensive doctors over less expensive nurses. And there is no control in the system”, said de Kervasdoué.

Couderc said: “There's a lot of treatment that could be done by nurses and not doctors. And there's too much money spent on emergency beds and not enough on convalescence that is much cheaper to provide.”

He added: “It's not a bad health system, but without putting a single centime more into it, it could be so much better.”

Isabelle Joumard, a senior economist at the OECD, and author of a recently published study, Systèmes de santé—efficacité et politiques, said indicators, such as hospital admissions for treatable conditions like asthma, reveal that while the French health system is costly it is actually efficient. Administration costs, however, are the second highest in the world—around 7% of total health costs: “If we need to save money we could start there”, she said.

Joumard believes reorganisation is also in order. “We have a higher length of hospitalisation and this reflects the fact that we have good acute care, but a lack of structures for ambulatory procedures, and less costly aftercare”, she said. “We need to look at a repartition of responsibilities between the actors in the health service and see if we can be more efficient. One thing currently under discussion is a sharing of responsibilities between various players in the heath service and the roles of hospitals, doctors, and doctors and nurses.”

Joumard believes the debate needs to be not just about cost but about equality of service. “We have found there is a fragmentation of health care meaning some social groups are better covered than others. The inequality needs to be at the heart of the debate”, she said. “The conclusion is that globally it's a very good system and it is certainly the envy of others. That's not to say it couldn't be improved.”

Socialist presidential candidate François Hollande, currently on track to become the country's next leader according to opinion polls, has pledged to reduce France's budget deficit to 3% of GDP, from the current 4•4%, by 2013, bringing it in line with European requirements.

Among the health measures in his 60-point manifesto is a proposal to limit doctors' fees over the statutory fee for reimbursement, and to reduce the price of medicines. He has also proposed that anyone in an advanced or terminal stage of an incurable illness might, under certain conditions, “benefit from medical assistance to terminate their life with dignity”.

In the political speeches in the past few weeks, however, health has barely merited a mention from any of the ten candidates. “There is no miracle solution. The things we have to do are difficult but we have to do them”, said Couderc. “That's why it's so strange we hear so little from the politicians. Nothing at all, in fact. It's aberrant that they have no ideas; no worse than that, it's lamentable and useless.”

Kim Willsher , Lancet 20.04.12