French Doctors Threaten to Resign in Public Health Crisis

Aude Lecrubier

January 24, 2020

More than 1000 French doctors, including 600 heads of service, have announced their "unprecedented and difficult decision" to resign from their administrative roles from 14th January 2020 if the "inadequacy" of recent emergency government measures is not rectified.

The announcement was made in an open letter, published in Libération on 13th January, to Agnès Buzyn, the French Minister of Health, in response to a three-point plan announced by the government on 20th November to improve staff morale, cut red tape and free-up additional resources.

The signatories to the letter, who numbered 1189 by 18th January, call for urgent high-level talks on public hospitals.

They say the government plan "is too little, too biased, too long to execute", explain the heads of services, administrators, Medical Executive Committee presidents and elected officials and healthcare and university medical department managers who signed the letter.

"Hospitals must be reformed, but major reforms will not be possible without the means," reads the letter, which was the brainchild of the Inter-Hospital Collective (IHC), led by André Grimaldi, professor emeritus of diabetes at CHU Pitié Salpêtrière.

At the End of the Line

Interviewed by Medscape France, Prof Francis Bérenbaum, head of rheumatology at l’hôpital Saint-Antoine, Paris, and a signatory to the letter, explained: "We are at the end of the line. You have to make a big noise to be heard. We have been sounding the alarm for years but at some point, it becomes no longer possible, no longer sustainable.

"The measures in the emergency plan are in the right direction but don’t go far enough. We see every day that we cannot hold out any longer. In our rheumatology service, for example, caregivers, nurses, managers, radiologists, physiotherapists, doctors and even some teachers are leaving, like you would never have imagined.

"It’s the same everywhere. No one can do their job. We cannot operate a hospital following the rules of commerce, like a supermarket."

At a press conference held at l’hôpital de la Pitié Salpêtrière, doctor after doctor testified to the deplorable working conditions and deterioration of care in public hospitals.

Prof Jean-Luc Jouve, head of paediatrics at La Timone, who made the trip from Marseille, painted a picture of a hospital in crisis: 16 out of 20 paediatric beds open; operations cancelled every day due to staff shortages; the inability to find a replacement for the retiring head of adult surgery, due to the poor image of public hospitals.

Everyone is Suffering

Prof Gilles Montalescot, cardiology chief at l’hôpital de la Pitié Salpétrière, explained to Medscape France why he signed the letter.

   

Prof Gilles Montalescot

"Everyone suffers in public hospitals. We suffer a little less when we are in a specialty, such as cardiology, that brings money to the hospital and we suffer a little less if we work in a large university hospital like la Pitié Salpétrière.

"While we may be the most active Heart Institute in Ile-de-France, we have huge personnel problems. Nurses are leaving every day. They can see very clearly that they are badly paid, are not respected and their living conditions are not acceptable. And this situation is even worse for care assistants.

"Finally, doctors are also starting to leave for private care or institutes with different working practices. Moreover, there is a shortage of beds, a shortage of paramedics and a lack of medical staff, including in cardiology, which is leading to a real degradation of care and suffering among caregivers, with a number of cases of burnout and depression."

How did we get here?

"The politics of health has not been optimal for decades. It should not be forgotten that the shortage of beds, the limited places in university faculties and the restriction in the number of places at nursing schools was chosen, decided upon. We are paying the price now.

"In addition, T2A [tariff payments for care] has transformed us into hamsters in a wheel, peddling endlessly to do our work. In cardiology, the more work you do, the more the hospital earns, which allows you to have some staff to fill the gaps. But there are disaster specialties such as paediatrics or psychiatry. For all chronic diseases that do not bring money, there is no rush to fill nursing vacancies.

"As far as we are concerned, we have reorganised. We have merged and moved into the same building as four Parisian cardiology services to be more efficient but that did not change the situation. In 2019, activity across all areas of cardiology increased by 5% compared with 2018. But revenues are down 12% because there are cuts, with social security reimbursements only decreasing. It’s a hellish system."

How do you see the future if nothing changes?

"I think we’re heading for English health in France. We see the sick left on stretchers, waiting lists the like of which has never been seen before, notably in cardiac surgery, and the cancellations of interventions due to staff being absent.

"These are situations that we do not know. We can see a kind of paradox in England, which has lived through these situations for a long time, announcing the recruitment of 50,000 nurses for the NHS.

"Our system was one of the best in the world and we are falling to the bottom of the tables, with talk about the difficulties of access to innovation or the difficulties in doing research today because the budgets are not ring-fenced and are often used to soak up hospital deficits..."

What do you expect from the government?

"I expect the French to be aware. This movement is not our movement. If health is important in their eyes, they must grab this movement head-on.

"Personally, it is not a trivial thing to offer my resignation as service chief and join the protests. I am not doing it for a particular reason but for French society. If we don’t act, we will end up with two-speed medicine for the more or less wealthy. In addition, we will have a system where we treat very well illnesses that bring in money and treat the rest badly."

The Support of 5000 Caregivers

The 1000-plus doctors are supported by 5000 caregivers, under the banner Health Personnel Collective, who published a letter of support, also in Libération.

"We, hospital staff of all kinds, lend our support to doctors, service heads, care unit managers or appointed or elected officials who have decided to collectively resign from their administrative, management and representative roles," write the nurses, healthcare managers and doctors.

"We support the call for high-level health talks. The doctors demand nothing for themselves. They continue to treat. The people must respond to their call. Their warning must be heard by the government," they underline.

The Doctors’ Demands

The signatories and the IHC demand, as a priority:

  1. A significant wage increase for non-medical staff and doctors without a permanent contract, in addition to the various bonuses announced, with the clear objective of catching up with the average salary in OECD countries. The demand for an increase of at least €300 net per month is legitimate.

  2. A national health spending target for 2020 that does not impose new cost savings on hospitals. To achieve this would require a further €600 million, in addition to the €200 million counted in the government’s new hospital plan (of the €300 million announced, €100 million has been allocated to medical care for the elderly).

  3. A major funding review, with the end of "all T2A" payment tariffs, to allow patients to receive the right care at the least cost to the community and encourage appropriate prescribing and procedures, rather than seeking profit-making activities, and to give medico-administrative co-management real autonomy, thanks to the inclusion of doctors, management, staff and end-users in governance.

  4. Hiring the personnel necessary to improve the quality of care and ensure safety, and assess the requirements for reopening beds, especially for emergency and acute care.

"We demand budgetary adjustments and the opening of negotiations to prepare, with the groups, patient representatives and unions, for high-level talks on public hospitals, with a plan that is both national and regional," says the IHC.

Some Statistics

According to the IHC:

  • France spends 11.2% of GDP (third among OECD countries) on health but, in dollars per inhabitant, we are in 12th position.

  • France is 28th out of 32 OECD countries for hospital nurse wages compared with the average national salary. To bring the average salary in line with the cost of living would cost around €500 per month.

  • The forecast for the natural evolution of healthcare spending by the social security department in the ministry of health was +4.3% in 2017 (4.75% for the city and 4% for the hospital), 4.5% in 2018 (5.1% for the city and 4% for the hospital) and 4.5% in 2019 (5.3% for the city and 3.7% for the hospital). For 2020, the forecast is +3.3% for the hospital, while the allocated budget increase is only 2.4%.

  • France devotes 3.6% of GDP for public hospitals versus 4.1% on average across Europe (France strategy 17/01/2019 "where to reduce the weight of public expenditure").

Translated and adapted from Medscape's French Edition

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