Former general practitioner then project manager in a regional health agency (ARS), Doctor Francis Fauconnier advocates, in a forum in the “World”, a new organization of the healthcare system.
The healthcare system has been severely tested by the current coronavirus crisis. In fact, it has malfunctioned for a long time, to the detriment of the population. It would have to be reviewed constructively. The main problem is the disparity of existing organizations, which have built up over decades.
The clearest separation is found between professionals practicing “in liberal” and those practicing in the hospital. This separation, which is continuously maintained, can be explained by the modes of financing which put in competition or, at least, do not encourage cooperation between these different professionals.
Hospital: Emmanuel Macron recognizes a “mistake in the strategy” and announces immediate consultation The methods of financing liberal professionals are individual and for the majority based on the remuneration of their personal activity, measured by the number of consultations, visits, acts listed in a nomenclature … Those of professionals working in the hospital are salaries, financed by the hospital budget, which depends on the activity of the establishment, measured by acts listed in another nomenclature, giving rise to an “activity rate”.
A set that malfunctions
Liberal professionals are thus placed in competition with each other. They are not affected by the financial problems of the hospital. For their part, professionals from the same hospital are potentially in competition with those working in neighboring health establishments. They are not concerned with the financial problems of liberal professionals.
All of this concerns the majority of situations and the majority of funding that rewards and influences professionals, whether they practice in a liberal setting or in the hospital. The authorities have tried – but this remains very marginal quantitatively – to encourage cooperation between liberals, between liberals and hospitals, and between hospitals. The reality is that on the whole it malfunctions.
The first brick, to build a new organization of care, would consist in bringing together, finally, general practitioners, practicing in liberal, whether “in town” or “in the countryside”, and hospital doctors. The other bricks would be made up of other “primary care” professionals, including nurses and physiotherapists and their hospital counterparts. Later, it would be necessary to associate specialists practicing in the city and / or in the clinic, as “secondary care” professionals.
The operation of the community health establishment
The laying of the first simple and direct brick, associating general practitioners and hospitals, the latter would be part, in a given geographical territory, of the same “community health establishment” (ESC). In such an organizational scheme, an ESC has governing bodies which include representatives of hospital doctors and general practitioners, in proportion to their number.
The funding of this ESC is just as simple and direct: it receives, for all of the care it usually gives, the sum hitherto paid to all the general practitioners and the hospital that are part of it. This sum, resulting from the addition of what the Health Insurance pays to each other each year, is paid to the ESC, in the form of monthly payments: it is the equivalent of a “global hospital budget” extended to general practitioners included in the ESC.
The doctors of the ESC have a common statute and a remuneration which can be adapted according to the choices of the establishment. Thus, the ESC can give the choice to general practitioners to be paid with a fixed salary, or by “capitation” (that is to say according to the number of patients registered on their list), and with accommodations individuals (for example on guards and on-call duty). These doctors could combine hospital and exercise in their offices.
Respect for good medical practices
Given the fact that it receives guaranteed funding, the Community Health Facility is accountable for the quality of care (in the broadest sense of these terms) to the population. He must be able to report to bodies acting on behalf of the population served, as well as to public authorities. The representation of users is therefore a particularly important body to develop and operate, with the support of bodies such as the Regional Health Agencies (ARS).
All organizations playing a role in respecting good medical practices, the proper use of medical resources and in that of the code of ethics are maintained, but transit via the ARS to tend towards administrative simplification. The expected benefit from the establishment of such a community health facility is an improvement in the health of the population.
At first analysis, this is measured by compliance with good medical practices, as defined and updated. To do this, the ESC is developing a computer system common to all doctors and is adapting its “Information Systems Medicalization Program” (PMSI) to make it a tool for monitoring hospitalizations – and home returns – patients cared for by its doctors.
Working together for the benefit of the population
The care and follow-up of chronic diseases, which are important and in continuous progression, is the responsibility of these professionals. This is measurable, and therefore objectifiable. For example, even with the current PMSI, we can already measure the number and duration of hospitalizations for complications of diabetes, in emergency or on a scheduled basis. We can therefore compare what ESC does with what it should do optimally, and help professionals to further improve their cooperation, for the benefit of patients.
The establishment of such a community health facility will take time, which must be counted in years, without that means that the objective is lost in quicksand. A strong cohesion on the main objective – to work together for the benefit of a population, in a measurable way – will make it possible to devote the time available to prepare and start such a project in all its human and technical aspects. To this brick will be added the following, that is to say the other primary care professionals, then the secondary care professionals.
Francis Fauconnier, a general practitioner for fifteen years then a social security consultant and project manager at the Regional Health Agency (ARS) Auvergne-Rhône-Alpes, is currently retired.