Difficulties in finding a general practitioner, recourse to delayed care, saturated emergencies, degraded health… Nearly 12% of French people today live in a medical desert, that is to say some seven million people. If nothing is done to reverse the trend quickly, there could be 20 million more by the end of the next five-year period, according to projections made exclusively for Express by Iqvia, a company expert in health data. , present in more than 140 countries. That is 27 million people in total deprived of simple access to a general practitioner.
While France has never had so many practicing doctors, their number is expected to decrease over the next few years, while the needs will increase. Often already complicated, access to care could therefore become very difficult, if not almost impossible, for many of our fellow citizens. “By crossing the evolutions of the population with the expected retirements of general practitioners and the number of young people in training, and by extending the trends in terms of settlement, we clearly see that the under-dense areas in the east and the center of the country should expand. Territorial differences are widening, and new sectors, relatively spared until now, are affected, starting with the southern and western suburbs of Paris”, notes Jean-Marc Aubert, president of Iqvia France and former director of Drees, the research and statistics department of the Ministry of Health.
Infographics
Dario Ungiusto / L’Express
“The situation is unacceptable, it represents a threat to the republican social pact”, recognizes Dr Jean-Marcel Mourgues, vice-president of the National Council of the Order of Physicians. The fault, as we know, of an excessively tight numerus clausus in the 1990s, when the promotions of medical doctors did not exceed 3,500. A major political error, when young doctors are now showing themselves less and less inclined to maintain the work rhythm of their elders. Often mentioned but never treated, the subject becomes a real emergency. Because all the data shows it: it is now that the difficulties will begin, with a particularly complicated decade ahead of us. Then, the number of doctors will start to rise again, thanks to the relaxation of the numerus clausus that has taken place in recent years.
Limited offer. 2 months for 1€ without commitment
Further increase the numerus clausus? “It’s no use anymore”
In the meantime, what palliatives can be found to get through this delicate period? All the candidates for the presidential election place the question at the top of their “health” programs, but the effectiveness of the treatments offered raises questions. Starting with the continuation of the increase in places in the faculties of medicine, promised by almost all applicants to the Elysée: “It is no longer useless: in ten years, when these future students will arrive in the cabinets, the problem will be solved. We need immediate answers”, notes Xavier Nicolas, co-responsible for the health commission of the Association of small towns in France and mayor of Senonches (Eure-et-Loir).
Infographics
Dario Ungiusto / L’Express
In recent years, public authorities have relied mainly on financial incentives. Obviously, the sums offered, although generous (up to 50,000 euros per doctor), are not enough. Some candidates nevertheless wish to continue on this path: Marine Le Pen thus wants to increase the price of consultations in medical deserts. Conversely, others are now leaning towards a more coercive policy. Yannick Jadot proposes a selective agreement (young doctors would only put their plate in over-endowed territories if they replace a retirement), and Emmanuel Macron evokes a “regulation of facilities”. However, he is careful not to detail this project, demanded by local elected officials but shouted down by doctors.
Variant on the same theme: impose on young graduates a few years of exercise in a desertified area (Yannick Jadot) or, on interns, a fourth year in these territories (Anne Hidalgo, Valérie Pécresse). “If necessary, we will be very careful that it is good training, and not just to provide a medical presence at low cost”, already warns Gaëtan Casanova, president of the National Intersyndicale of interns. The hope: that these young people stay after having had a taste of rural life and exercise in the countryside. Problem, it was already the idea of the third year internships of general medicine internship. With an often mixed result: “For nine years, the nursing home where I practice has welcomed four interns per semester, and none have continued here. Their family ties are elsewhere, or there is no job. for their spouse”, notes Dr Mathieu Lapallus, general practitioner in Charlieu, 3,600 inhabitants, in the north of the Loire. He decided to settle here about fifteen years ago because he was “a child of the country”. But in his corner of France lost between Roanne and Lyon, his colleagues are retiring one after the other, without replacements. “Two pharmacists had to open telemedicine booths in their pharmacies to maintain their sales, because their customers could not even get their prescriptions renewed”, says Isabelle Dugelet, mayor of the neighboring town of La Gresle.
Banner on the side of a road indicating the search for doctors, France. France (Photo by GARO / Phanie / Phanie via AFP)
GARO / Phanie / AFP
Under these conditions, what other remedies can be imagined? Salary of doctors (Eric Zemmour)? Continue to cover the territory of nursing homes (Jean-Luc Mélenchon, Marine Le Pen)? “In both cases, the candidates do not jostle. And the employees are expensive: the Center-Val de Loire is experimenting with this solution, at the cost of a deficit of 20,000 euros per year and per doctor. , I already know several that remain empty”, answers Xavier Nicolas. Faced with daily requests from patients looking for a general practitioner, a sine qua non for being reimbursed at the full rate by Health Insurance, Mathieu Lapallus decided to take up one of the latest reforms to date: the possibility of collaborate with an “advanced practice nurse” (IPA), for the follow-up of their stabilized chronic patients. What, he hopes, will free up niches and accept new patients.
Only short-term track: free up medical time
“Saving medical time by better distributing the activity between healthcare professionals is really the central question. Abroad, general practitioners often have larger patient populations than their French colleagues, thanks to a different distribution of tasks between caregivers”, confirm Julien Mousques and Guillaume Chevillard, researchers at the Institute for Research and Documentation in Health Economics (Irdes). However, the new profession of IPA remains underdeveloped: at the end of 2021, only 800 were in practice, according to Health Insurance. Some doctors remain very opposed to this innovation, torn between fears for the care of their patients, and fear of future competition, according to a report by the General Inspectorate of Social Affairs. “Access to IPAs has been locked: abroad, patients can often request them directly, whereas in France, they must go through the attending physician”, note the two researchers from Irdes. As for the idea of sharing tasks with other professionals (pharmacists, physiotherapists, etc.), mentioned by Emmanuel Macron in particular, it also arouses mistrust: “We prefer to talk about working in delegation, rather than transferring In other words, the doctor must remain the conductor of the care received by the patient”, insists Dr Franck Devulder, president of the CSMF (Confederation of French medical unions).
In reality, these reforms come up against a major obstacle: the payment of doctors on a fee-for-service basis. “It pushes to maximize contacts. On the contrary, a fixed remuneration per patient encourages to follow more, even if it means seeing them less often”, analyze Julien Mousques and Guillaume Chevillard. Only here, for the liberals, the mode of remuneration remains at least as taboo as the freedom of installation… But as we must find solutions to save time for our practitioners, the public authorities have recently invented another profession: medical assistant. These super secretaries were however less than 3,000 at the end of last year, for 85,000 generalists in practice. Practitioners are asking for them, but this time it seems that it is Social Security that hesitated to open its portfolio too widely: “To obtain funding, you have to commit to increasing your activity, while our colleagues were above all asking to be relieved of certain administrative tasks to breathe a little”, regrets Jacques Battistoni, the president of the union MG-France.
Life expectancy gaps
To improve the organization of caregivers in the field, other reforms have been launched in recent years: the professional territorial health communities (CPTS) and the care access services (SAS, tested in some regions). In both cases, it is in particular a question of pushing the liberals to coordinate so as to take charge of “unscheduled care”, these requests for appointments which are not emergencies but cannot wait more than 24 hours. to 48 hours… Two years after their launch, the CPTS cover only 32.5% of the population, according to Medicare. The SAS, on the other hand, suffers from abstruse funding rules, assures Dr. Devulder: “The price varies according to the number of patients, and the money is paid after one year…”. In the field, their implementation is often done in pain: “It’s a gas plant, gets angry Benoit Labenne, general practitioner in Seine-Saint-Denis. In the department, we multiply the meetings but between the heads the Samu of liberal regulation, the CPTS, no one can come to an agreement…”
L’application L’Express
To track analysis and decryption wherever you are
Download the app
However, the next government will have to succeed in convincing GPs to work differently. The renegotiation at the end of the year of the medical convention, the text which binds liberal doctors to Health Insurance and determines the terms of their remuneration, will be an opportunity not to be missed in an attempt to avoid a health crash for our country. . Already, a study carried out by the geographer Emmanuel Vigneron for the Association of Rural Mayors of France shows that the gaps in life expectancy between the most remote areas and the big cities are widening. While many factors explain these differences, inequalities in access to care play a large part in them.
Opinions
Tribune
Chronic
Chronic
Chronic
