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In July 2001, France's Minister of Employment and Solidarity held a second meeting on the future of the healthcare system, bringing together experts, healthcare professionals and social partner representatives. The context is a rising level of health expenditure and problems in areas such as relations between healthcare professionals, the state and sickness insurance funds. Despite the pressing nature of the issues at stake, the meeting produced relatively few concrete results.
In light of soaring health spending and deteriorating relations with self-employed healthcare professionals, the Minister of Employment and Solidarity organised an initial meeting with all categories of healthcare professionals on 25 January 2001. On the strength of this meeting, the Minister set up a 'consultation exercise on overhauling general medicine', involving experts in the field, which was to submit a report by the end of the first half of 2001.
Background to July meeting
A second meeting was held on 12 July 2001 under significantly changed circumstances:
- in terms of health policies, in a grouping of three medical practitioners''' associations and four trade union confederations (CFE-CGC, CFTC, CGT and CGT-FO), commonly known as the G7, put forward an 'ambitious plan to reform sickness insurance' in May 2001 (FR0105157F). A second group, commonly referred to as the G14, made up of two other union confederations (CFDT and UNSA), the two main associations of mutual health insurers, a general practitioners' association and numerous self-employed paramedics' organisations also tabled proposals. Consequently, prior to the 12 July 2001 meeting, the G7 and G14 had both proposed solutions and the expert consultative group set up by the Minister had submitted its report; and
- at a more comprehensive level, the MEDEF employers' confederation has recently taken two initiatives. Given the major role played by the state in health-related issues, the employers' organisation has postponed the discussions to be held on sickness insurance under its current 'industrial relation overhaul' project (FR0102134F). Second, MEDEF, which opposes the measures taken by the government to fund the present reduction of the working week out of social security fund surpluses (FR9910112F), announced in June 2001 that its representatives would not be seeking re-election to the boards of all jointly-managed social security funds (sickness insurance, pension and family allowance funds) (FR0107167N). For his part, the Prime Minister let it be known in June that he was ready to convene talks on 'overhauling industrial relations'. This would include the future of the social security system.
In an attempt to take these developments into consideration, the 12 July 2001 meeting was extended beyond healthcare professionals to include employers' organisations as well as representatives of trade unions and the pharmaceutical industry.
Limited progress
It appears that only minor progress was made at the July meeting. Based on proposals put forward by the expert consultative group, the Minister announced some widely-agreed measures, but as far as the core issues of the debate were concerned - relations between doctors and the sickness insurance fund and between the sickness insurance fund and the state, and the control of health-related spending - she was able only to announce further talks.
It was decided that, in line with the proposals of the expert consultative group a 'national observatory on demographics and healthcare professions' (Observatoire national de la démographie et des métiers de santé) is to be set up. Furthermore, assistance for healthcare professionals setting up in rural areas was announced. The idea of creating a National Health Council (Conseil national de la santé) to 'advise the government, parliament and the French public on the choices required for healthcare' was adopted, though the Council's actual make-up and jurisdiction are yet to be set. Finally in an attempt to give real substance to health policy, the Minister has pledged to allow parliament to debate the goals of health policy each year before it debates the social security funding bill (FR0011104F). A commitment was also made to improving the ways in which healthcare professionals and the social partners are consulted before the financial goals of health spending are set.
Points still under discussion
At the July meeting, the Minister announced further talks on delicate issues, as follows.
- On the issues of relations between healthcare professionals and the sickness insurance funds, the G7 is demanding a return to a single agreement between professionals and funds, while the G14 is suggesting a common core and a second optional level, so as to allow for genuine contracts between doctors and the funds so as to link 'fee increases in the professions to measurable requirements'. As for the expert consultative group, it is suggesting a three-level agreement: a common core; a second level unique to each profession; and a third level for optional 'individual contracts on good private practice commitments'. As far as these issues are concerned, the Minister is expecting further proposals from the various parties over the coming months.
- In terms of the relations between the state and the sickness insurance fund, the G14 has reasserted that responsibility for setting public health policy and making budgetary choices lies with the state. However, it is demanding that the sickness insurance fund be given a 'clear and indisputable management mandate by the state on matters under its jurisdiction'. The expert consultative group is suggesting that the current jurisdiction of the sickness insurance fund be extended to cover all general medicine, including spending on drugs. The clarification of the roles of the state and the sickness insurance fund is an issue that is to be discussed under the 'industrial relations overhaul' project, as part of overall discussions on the social security system.
- On the issue of controlling spending, the G7 is demanding a 'multi-annual readjusted projected target, not binding on healthcare professionals'. The expert consultative group is thinking more along the lines of 'credible', yet binding 'multi-annual targets'. In order to appease healthcare professionals, the group is suggesting that payment rate cuts imposed on professionals be repealed. The Minister, however, stated that for want of a better system 'we have to keep the one we have despite its failings'. The Minister has not rejected the principle of multi-annual targets but maintains that their impact must be assessed more accurately.
Outstanding issues
Three further issues dealt with in the report of the expert consultative group were barely mentioned. The G7 has proposed that doctors' fees be raised significantly from FRF 115 to FRF 196 per treatment, while the G14 is suggesting that some remuneration should be tied into professionals' contract commitments. The expert group, an attempt to gradually bring the income of general practitioners and specialists into line, is proposing to replace fixed pay systems - used in particular for on-call duty, mass prevention schemes and healthcare coordination - with a mixed system combining fixed and treatment-based fees. The issue of the collective and individual assessment of healthcare professionals has been raised. In its report, the expert group regrets that no definite proposal was put forward on this issue.
Commentary
The beginning of the pre-electoral period (presidential elections are to be held in spring 2002) makes decisions on complex matters such as healthcare difficult. However, soaring health spending and the operation of the sickness insurance fund, combined with MEDEF's planned pull-out from social security fund administrative boards, mean that this issue cannot wait. The social security funding bill, which will set spending for healthcare in 2002, and the healthcare system modernisation bill, which the Minister has confirmed is to be tabled in parliament in autumn 2001, will have to provide some hint of solutions. (Pierre Volovitch, IRES)