opinion | Review the governance of the health system

Posted on April 8, 2022 at 4:00 pm

For 30 years, the hospital crisis has been the talk of the town. It has settled in our healthcare landscape. Despite the laws and reforms that occur at a sustained pace, the situation of the hospital is very similar to that of the early 2000s. It is marked by the reduction in the number of establishments and the capacity of hospital beds, by the explosion in the number of emergency room visits, staff dissatisfaction, as well as persistent difficulties accessing care.

anomalies that accumulate

Is it acceptable that some departments do not have doctors for common medical specialties? That nurses travel more than 300 kilometers a day to care for fragile and isolated people? Is it acceptable that people after outpatient care due to lack of intermediate structures are “returned” to their homes without benefiting from a safe environment conducive to their return home? What solutions can we propose for our elderly or for vulnerable populations whose mobility is usually very restricted?

The hospital crisis is above all systemic

The 2007 hospital plan, the 2009 hospital, patient health and territories law, the 2012 hospital plan, the 2016 health law, the Ma Santé 2022 program and, more recently, the Ségur de la santé have failed mitigate these dysfunctions or even actually reverse the trend.

The situation is all the more worrying as these dysfunctions are likely to increase with the aging of the population, the chronification of many diseases, the shortage of health personnel (which the WHO has been warning about for more than 20 years), more and more expensive technologies and treatments, all in a context of controlling health costs.

The latter, although suspended for the last two years, is a long-term trend. The hospital crisis is, therefore, above all systemic. It feeds on tensions and even contradictions generated by political reformism out of tune with the socio-medical reality. It is meant to last without deep action.

Building a less pyramid-shaped health organization

Above all, the public hospital supplies the lack of alternative solutions, especially in areas where the shortage of offers is notorious. The commitment of hospital health professionals is eroding. It results in physical and mental exhaustion that undermines the long-term viability of the French hospital system.

One way is to build a new health organization that is less pyramidal, more reticular, to go beyond the hospital-centric, historically and culturally anchored approach. Such a project requires rethinking health and medical-social action around a renewed governance of the health system, reviewing the distribution of powers among the different actors; the State, health insurance, local authorities, public and private health establishments, city medicine.

The challenge is to get out of the top-down model of public policies and actions to build a balance based on the multilevel alliance of all categories of actors so that they can collectively contribute to the definition of common actions and projects, respecting their territories and as close as possible to users.

An overly timid opening towards local communities

The 3DS law (Differentiation, Decentralization, Deconcentration, Simplification) definitively approved by the National Assembly and the Senate last February gives some indications of a still timid opening towards local authorities. It allows them to participate in the definition of the territorial supply of care. The effectiveness of this new reform will depend on the commitment of these local elected representatives and the financial capacities of their communities, which we know are limited.

The construction of this territorial governance is a challenge that cannot be delayed forever at the risk of further compromising equal access to the health system and its quality.

Laurent Meriade is a professor and Corinne Rochette is a university professor at IAE Clermont Auvergne. With “The Revue française de gestion”.

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