Emmanuel Macron is out to do a “relooking”. In the Wall Street English version of modern French that the President loves to prove he is fluent in, it means to adopt a new hair style, to repaint your kitchen or, in his case, to offer in a tone of fake seriousness during his fourth national TV address of the epidemic, a slogan that he has tried to tart up a bit: France’s “after Covid” needs to be a time when the economy is “strong, green, sovereign and one of solidarity”.
It was a real iron fist in a velvet glove: no increase in taxes on the rich or on companies, many of them bulging with cash, but watch out you on the shopfloor as “our country is going to experience multiple bankruptcies and workforce reduction plans” and all need to “work more”.
Five hundred billion Euros had been pumped into the economy, he reminded his Sunday evening viewers. But for the health services that had been the front defence against the virus? Talks had begun with all concerned, staff would see their jobs “revalued” and there would be “new investments”. That politician’s promise has been on the table for over two months now. As I said, a “relooking”.
Christophe Prudhomme, an emergency ward doctor, represents the AMUF, the Association of A&E Doctors of France. “I have to go. I’m on the ward. More patients are coming in,” were the last words I had had from him in late March just after the lockdown closed in across France. Three months later we could be more relaxed, and explore in greater detail what needs to be done to take forward a health system whose excellence French governments have vaunted across the world.
Did you read “system”? That term so loved of Macron and his ministers as in their constant claims that, against Covid-19, “The system has held”? It is easy to get swept up in the official rhetoric, the surround sound of politically-motivated phrases designed to mesmerise the innocent into accepting that the powerful are not blame.
Easy, but mistaken. For “the system” did not hold. It was the personnel who took up the slack, who delivered the longer hours, who cared for patients when protective gear was not available, who went the extra mile and more. “The system” was what got in their way, had shut the facilities they needed, destroyed the resources, locked up the wards, sold off the beds for scrap, pretended there were no storm clouds on the horizon, right up to the very, very last moment.
They had marched, lobbied, heckled and shouted, they had been on strike, petitioned and paraded, they had warned that the belts tightening around them and their services were a formula for catastrophe for those they should be able to care for properly. And on that they had the public with them. For weeks they have been holding protests on Tuesdays and Thursdays outside their hospitals.
Now, on the ebb tide of the epidemic, “the system” is trying to get back into the driving seat. Macron and his Health Minister Olivier Véran have opened a national discussion on the way forward. They have talked of those additional resources, hinted at possible supplements to pay, suggested there may be some re-organisation, some greater “freedom” for hospitals. But, amid the crescendo of announcements heralding billions for the giants of private industry, commerce and finance, there has not yet been one centime more for the health service.
Amid the crescendo of announcements heralding billions for the giants of private industry, commerce and finance, there has not yet been one centime more for the health service.
What follows is what Christophe Prudhomme told me as he and his colleagues geared up for a national day of action across every hospital in France on Tuesday 16 June.
The system did not hold
“The atmosphere in our hospitals is one of anger. The President, the Prime Minister and some leaders in the health system have told us that ‘the system held’. But it did not. We sought to deliver the least worst result in face of the epidemic. Look at Germany. Had we had the same number of beds as Germany, if we had had 15,000 resus bed at the start of the epidemic, there would not have been a crisis.
It would have been necessary to reorganise a number of services, to reinforce some of them. But we would not have faced difficulties in finding hospital places for people, particularly when it came to the elderly.
Take for instance the famous health trains, the TGVs that took patients from the East and Paris to other parts of France, were a catastrophe. There were deaths in some of them. They took up a lot of time and personnel when other solutions were possible. It would have been more sensible to transfer staff and equipment rather than to move patients in this way.
We could have prepared venues like the Hôtel Dieu hospital, in the very centre of Paris just beside Notre Dame, and which has seen its wards progressively shut down over the last couple of years. We could have got those wards equipped and running again more quickly than the glorious French army which spent a full fortnight getting some tents and resus beds in place in the eastern region back in March.
Helped by a part of the medical profession, governments have argued that a lot of beds could be closed as patients can now be treated in walk-in clinics. Day-patients can come in the morning and leave in the evening. That is perfectly possible for a small percentage of patients, particularly those needing only minor surgery. But that is now only a small part of hospital work.
The evolution of medicine in developed, wealthy countries combined with the ageing of the population means that we are treating patients who are now older, whose conditions are more usually chronic and when they need a stay in hospital it is often long.
Medecine of the town
A policy based on closing services and hospitals has been helped by the fact that the French health system is a fully hybrid one. We have a mixture of public and private services and a parallel divide between hospitals and what we call ‘the medicine of the town’, in effect what is done outside the hospital. A proportion of the medical profession has campaigned for a reduction in the role of hospitals in order to augment that of the médecine de ville.
A problem here has been that this part of the medical services is principally run by GPs and a peculiarity of the French system has been that we have trained a lot of specialists for the hospitals and few generalists. Moreover GPs are at the bottom of the ladder when it comes to professional recognition and pay. Alongside the GPs, who are not employees of the health service but are paid for each patient visit that they have, this médecine de ville includes all sorts of private enterprises, small or large, and specialists paid, again, according to each action delivered, whether it is private laboratories who do the blood and urine tests, the X-rays or MRI scans, and so on.
Against this background, the system today is heading into the wall. Its decline had been accelerating since the start of the century as spending has not taken into account the problems that the health system faces while successive governments have exploited the division between hospital and non-hospital medicine in order to further reduce spending.
The principle behind the NHS in Britain, its unity, is what enabled it to be very effective and cost-efficient. Its problem is that it is paid for directly by the government out of taxes. When the government decides to cut the budget, it can do so more easily. The advantage – and the inconvenience – of the French system is that it has a mixture of the public and the private., Yes, this involves a higher cost. At the same time, health expenditure has remained historically high because the spending comes not from taxation but via the social security system, funded from contributions from salaries and enterprises.
Successive governments in France has wanted to shift funding to the taxation system to enable them to repeat what has been done in Britain and break up the French public health system, or at least reduce it to a minimum, and open the way to domination of our service by private money.
An aspect of this has been the way the government has pursued a policy of closing small local hospitals and concentrating hospital facilities in the large towns in the name of cutting costs. This has been, and will be, a catastrophe. The Gilets jaunes movement, for instance, highlighted the way in which small town France has seen its public services, whether the railway station, the post office, the school, or the hospital, closed down.
One of the features of France is the way in which we have a very high concentration of population in a limited number of urban areas with wide parts of the country having only a scattered population. The free market policy of the present government is continuing to push services toward the large cities. One idea behind this is that giant new hospitals can pull in foreign patients who will pay for their treatment – a commercialisation of French health provision at the international level – while whole areas of the country have weaker and weaker health services.
Our vision is different. We want to end the division in the system, with the médecine de ville revalued with health centres grouping the services, doctors and specialists working collectively, no longer paid according to each task performed but as salaried staff. The whole system would be financed via a single social security fund. This would replace the present system under which a complementary structure of medical assurance that individuals have to pay into covers the health costs that the state has decided will not be funded by the social security system.
The government has put through a special law that allows employees to show their thanks to health workers by donating a day from their holiday pay to the health service. That’s mad.
A single public service
The dual funding process is why the French health service is so expensive and inefficient. The public private mixture creates additional costs at ever level. The practice of paying practitioners for each health treatment means that to earn their living they always need to do more. It becomes quantity that counts and not the quality of the treatment.
There is a great deal of public support for what we are saying. We have been in action for over a year now. The Covid crisis has demonstrated to the public that our arguments are justified. We are confident that a significant majority thinks that the health service should be a properly-funded public one, and that the policies pursued in recent years have been wrong.
We will continue to campaign for a single, public service, financed solely from the social security system and eliminating what remains of the private, productivist system, a system that leaves the hospital patient as if on a production line in a factory or, when using the médecine de ville, in the hands of practitioners who need to constantly multiply the number of treatments.
The government has put through a special law that allows employees to show their thanks to health workers by donating a day from their holiday pay to the health service. That’s mad. We are asking instead that people use that paid leave day to join us in our campaign for a public health system in France.”