Far from being a few marginal adjustments, this is a real change in the organization of our health system that the public authorities should promote without delay. Without wanting to upset anyone, it is impossible to transform the modes of action and the institutions in charge of prevention, care and rehabilitation, the three pillars of a real health system adapted to the needs of the population.
Focused almost exclusively on care, our lame system is unnecessarily expensive for mediocre results. Sweden, which is otherwise better organized, only provides its population with 2.1 hospital beds per 1,000 inhabitants, while France has 5.8 per 1,000, almost three times more. Result? The life expectancy in good health of the Swedes is 72 years, compared to 65 for the refractory Gauls! Find the mistake.
Sweden has much more effective and better-networked means of prevention and primary care than our country, where hospital unions chant “more beds, more staff, more money” all day long without ever questioning the overflow of establishments with mediocre activity. Liberal medicine, for its part, with the cry of “don’t touch my freedom to set up and prescribe!”, refuses to revise its methods of practice from another age.
Activity-based pricing
Faced with this disorder, our political leaders, paralyzed, are playing with simple half-measures for fear of a corporatist conflagration. However, it is high time to have the courage to launch real reforms around the following axes.
First, reduce the number of hospitals by transforming the more than one hundred establishments with too low a surgical and obstetrical flow to be efficient. We will maintain the buildings and staff to create first-line “Health Cities”, developing the tools necessary for massive primary and secondary prevention actions, taking charge of routine care and minor emergencies, ensuring rehabilitation, offering premises to patient associations and working in concert with larger hospital groups as well as with neighboring professional health territory communities.
Second, adopt activity-based pricing. Contrary to what its detractors say, it is virtuous. But on the express condition, never observed, of financing the establishments on the basis of a permanent evaluation of the quality of the services provided. Are they justified and correctly carried out? In the absence of such control, the drift of an excess of unnecessary and sometimes dangerous acts will continue to harm patients while weighing down the accounts of Social Security. It is a real shame: how dare we accept variations of 1 to 5 in the installation of cardiac stents or bariatric surgery?
Liberal medicine is dying
Third: realize that liberal medicine, as defended by some unions, is dying. The younger generation of doctors mostly prefers salaried employment or remuneration based on hourly rates and capitation rather than per act, a method of remuneration that can be explained in particular by the increase in the frequency of longer consultations with older patients. Freedom of establishment must disappear as is already the case for pharmacists and nurses, allowing a territorial network adapted to the size of the population.
Fourth, integrate into our policies the considerable help offered by AI and robotics technologies, which are completely changing practices. In light of these new digital technologies and the strengthening of the role of other professionals in terms of diagnosis and therapeutic indications, the traditional model based on the obligatory passage through the medical prescription is collapsing. Consequence: increasing the number of medical students makes no sense, except to train future unemployed people in 2040.
Guy Vallancien is a member of the Academy of Medicine.
