Why is the hospital reaching “a breaking point”, as Rémi Salomon pointed out?

The moment of final death is not yet known, but the conclusion is there, very bitter: “the hospital is reaching a breaking point, it is cracking everywhere”, Rémi Salomon recently declared on TF1. And the president of the Medical Establishment Commission (CME) of the AP-HP to add a few more nails to the coffin: “There is a wear that occurs on the waves in a hospital that was no longer very fit before the pandemic” . . “Coronavirus and variants, flu epidemic or discomfort of caregivers… 20 minutes takes stock of Rémi Salomon’s statement and why the hospital is in so much pain today.

Where is the hospital?

As of April 12, 24,693 people are hospitalized in France due to the coronavirus epidemic. Among them, 1,644 are in critical care. These figures have been on the rise for a few weeks, while the drop in cases seems to have stopped, raising fears of a plateau in this high level of hospitalizations. Added to this, due to the Omicron variant, there is a very, very high number of positive cases. Currently, more than 130,000 cases are detected each day, according to the latest figures from Public Health France. As a result, many caregivers test positive for the virus and therefore have to stop working.

“In the emergency room of the Orleans hospital, for example, 90% of caregivers are on sick leave, citing their suffering at work. “Relative” emergencies are no longer accepted. These psychological consequences of long-term exhaustion must also be taken into account, because they will undoubtedly be the next big cause of quitting smoking. [maladie ou de carrière] among caregivers, details Mickaël Ehrminger, physician and public health researcher. Hospitals have human resource problems and white plans have been launched successively for two years, adding to the exhaustion of caregivers who are already highly mobilized. »

The coronavirus, the main culprit?

Answer: No. Bad news often came by squad, France experienced strong epidemics of influenza and gastroenteritis. “Serious cases of these pathologies, which are considered benign, require important care and emergency hospitalizations. The flu still does not seem to have reached its peak, which is later than usual, but, incidence level, we are already above the peak of the 2019-2020 epidemic, ”specifies the doctor. According to Public Health France, the number of hospitalizations for influenza increased last week compared to the previous one (1,089 in week 13 vs. 929 in week 12, or +17%).

And if the Covid-19 pandemic dealt a severe blow to the hospital, it no longer breathed serenity before the arrival of the PCR tests, variants and confinements. Devastating budget cuts had weakened the system. Two culprits are singled out: T2A for “activity-based pricing” and Ondam for “national health insurance spending target.” A note from the Terra Nova think tank shows in particular that the growth in healthcare production (+18.7%) was accompanied by a much smaller increase in the workforce (+3.4%), between 2009 and 2019. “Hospitals due to a deteriorating financial situation, they had to reduce their investments. They invested around 11% of their income in 2010-2011, compared to only 5.2% in 2018,” explains the note, which concludes that the Odams “have weighed on the resources of public hospitals despite the fact that they were giving more attention. “Hospitals have only been able to deal with this situation thanks to an absolute and relative reduction in the remuneration of their staff, due to an intensification of work and a reduction in investment”, analyzes Terra Nova.

The implementation of the T2A “was a fundamental element that inclined a public service towards a logic of profitability and economic competition. Therefore, working conditions deteriorate and the hospital has to compensate for the lack of doctors in the city. However, this is not its main mission, which is to offer a platform for technical and specialized care and emergency care to guarantee continuity of care”, argues Mickaël Ehrminger. And to continue: “The care professions are no longer a dream. More than ever, it is a priesthood: working conditions are degraded, making work degrading due to lack of time and resources. The caregivers no longer have the impression that they do their job well, especially since the salaries are low and the assessment non-existent. »

What are the ways to save the hospital?

A senate commission of inquiry has investigated this vast question. In his report, published on March 31, he recommends “quickly turning the page to ‘all T2A'”, and changing the Ondam, which must be based “according to health needs”, and no longer with the standards of “expenditure control public as an end. The Ségur de la Santé is also crushed there, judged as a response “too late in view of the antiquity of the hospital crisis”.

Finally, to combat the feeling of “loss of meaning” of caregivers, the commission proposes a ratio of patients per caregiver that must not be exceeded, as already exists in certain services, in particular resuscitation: “Adjusted critical thresholds on the activities The number of establishments must be defined and an alert mechanism established when they are reached. »

“There is no magic wand, solutions can take several years to implement. The hospital’s financing method must be completely revised to give a breath of fresh air to the services, and coordination with city medicine must be improved, ”says Mickaël Ehrminger. According to the doctor, the hospital cannot (or no longer) absorb routine consultations and “external health centers could attend to this problem.” And, finally, the public health researcher assures that “it would be better if a true prevention policy were put in place, because France is one of the countries with a very high premature morbidity and mortality.” [tabagisme et consommation d’alcool élevé] that require heavy and prolonged care that could be avoided. »

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