'Non!' to super-CEO
Opposition emerges to French plan to re-engineer hospital system, but Legislature is expected to bow to the Presidential will, writes John Brosky
‘No other country in the world spends more on hospitals than France,’ President Nicolas Sarkozy declared as he rallied support for a controversial restructuring of the French hospital system and cut off arguments calling for greater financing to accompany the proposed changes.
The overhaul of hospital administration and regional organisation proposed by Sarkozy through the Minister of Health, Roselyne Bachelot, is on a fast-track for approval and if no significant debate slows its course, the measures described in the act Hospital, Patient, Health and Regions (HPST; Hôpital, Patient, Santé et Territoire) will become law by the end of June.
‘Do not fear reform,’ said President Sarkozy. ‘Who would tell me to keep the status quo for hospitals. No one.’
With a majority in both the National Assembly and the Senate, Sarkozy has every chance of pushing through the main points of HPST that would give new decision-making powers to a newly empowered CEO, or super-Boss, for public hospitals that will in turn serve as the hub for re-engineered regional healthcare clusters.
‘No human endeavour can function without a leader,’ said Sarkozy, ‘I call it a “boss”. I realise I’m taking a risk saying that.’
The law also spells out a series of rules and incentives for new Regional Health Authorities (ARS; Agences Régionales de Santé) to encourage general practitioners and specialists to move back into rural regions that are currently underserved.
To defuse opposition, the government separated these measures for restructuring France’s healthcare administration from financing measures that are addressed in the Social Security Financing Law (LFSS 2010; Loi de Financement de la Sécurité Sociale) and for capital investment in the plan Hôpital 2012.
Yet HPST is charged with enough controversial proposals to have provoked a widespread opposition from medical professionals, who say they are being pushed out of decision-making, from regional authorities who see their powers being undermined, and from unions of nurses and caregivers, who are threatened by the spirit of a law calling for a public hospital to be run like a private business.
Introduced in February by Health Minister Bachelot, the fast-track plan calls for just one reading and vote in each house of the French Parliament, to be followed by a revision by a joint commission that will reconcile modifications.
After a long debate, but with no amendment to the major themes proposed by the Presidency, HPST was approved by the National Assembly in March and the Senate is expected to pass an amended text by the end of May, though the Bachelot law has run into an unexpected opposition.
Seizing upon an uproar among medical professionals, the Senate intends to modify the text saying ‘Non’ to giving CEO status to hospital directors, and ‘Yes’ to returning doctors to hospital governance, according to former Prime Minister Jean-Pierre Raffarin, who serves as a Senator from the Vienne region and is a leading member in the party of President Sarkozy, the Union for a Presidential Majority.
In a televised interview, Senator Raffarin clearly was enjoying the new powers of the French Senate, which he played a key role winning in 2008, as he criticised the text approved by the Assembly as ‘too complex and not quite clear’.
‘We are not here to lie down to any text sent over from the Assembly,’ he said. ‘This is not a revolution, but it is showing something of a rebellious spirit,’ he said.
Despite its fast-track status, a prolonged stay in the Assembly and a detailed study ahead of debate in the Senate has given physicians an opportunity to gather their strength.
Angry that their counterproposals were not taken into consideration, the heads of the medical committees for France’s leading hospitals in a press conference greeted the passage of the Bachelot law by the Assembly with a threat to quit their posts and suspend participation in hospital planning
‘Contrary to what is being said, the law is not going to expand the role of doctors in the operations of the hospital,’ said Alain Destée, a neurologist with the Centre Hopitalière Universitaire (CHU) de Lille and President of the Conference of Presidents of the Medical Committees (CME; commission médicale d’établissement) for the CHUs.
Given a weak role in the selection of the super-CEO, the CME presidents protest that they will be absent from planning objectives and budget with the head of the regional authorities, as well as cut out of internal contracting discussions that are vital to ‘spell out and sustain the medical orientation’ of the hospital.
Meanwhile French Hospital Federation (FHF) has fallen into line with the government, with Executive Director Gérard Vincent saying, ‘There needs to be an orchestra leader, someone who can take decisions, and that is what is missing today.’
Vincent said FHF favours this spirit in the reform law and supports the creation of regional health authorities, saying the challenge today is to ‘free up the energies in the departments so that a real wind of change will bring change to the current range of healthcare services and respond to the expectations of both medical professionals and patients’.
Guillaume Sublet, head of Economic Intelligence and Regulatory Affairs with Nextep Consulting & Health Economics in Paris, predicts that despite the rebellious bravado of former Prime Minister Raffarin, the French Senate will ultimately have to vote with President Sarkozy’s position in mind. ‘The President was very clear,’ said Sublet, who manages an online forum of interviews with leading players in the debate over the hospital reform. ‘Medical practitioners may win some points about their importance, ‘but we can expect that, just as in the National Assembly, the core text will pass without significant modification and French hospitals will walk the President’s line with a hospital chief executive leading a management inspired by the private enterprise model.’
01.05.2009
