French hospital system in crisis: open letter signed by 1000 doctors and health professionals from France's top hospitals

This is a translation of an article in "Libération" published on Tuesday 16th January - "Hôpital - Mille signatures et une urgence" ("Hospital - one thousand signatures and one emergency"). The letter starts: "We, hospital doctors and health service managers...."

An appeal by Professors André Grimaldi and Jean-Paul Vernant and Dr Anne Gervais of the University Hospital Centre of Grenoble [one of the top ten hospitals in France] has been co-signed by over one thousand other hospital professionals throughout France, warning of crisis in the hospital system.

Further cuts of 1.6Bn Euros have been imposed on hospitals. Their budget for 2018 will only increase by 2% while their workload will increase by more than 4% (public hospitals spend 36% of all health-related expenditure). In order to balance the budget the tariffs in the list of "tariffs by activity" ("T2A") will be cut once again. In order to try to keep their accounts in balance hospitals are forced to increase their activity year on year while reducing the number of staff. Always "doing more with less" means worse working conditions leading to an exhausted and demoralised workforce and, in consequence, poorer quality care. As the minister of health conceded: "We have come to the end of this phase and this system. For example, with T2A the system was supposed to make public hospitals believe that they are [profit-making] enterprises".

The letter:

"We, hospital doctors and health service managers, putting aside political or union affiliations, support the aim of the minister for health to improve the relevance of care offered by reducing the unjustified diversity of medical practices, by reducing the number of prescriptions for unnecessary [diagnostic] investigations, by improving co-operation between social care and hospital care, by choosing ambulatory care wherever it does not compromise the overall quality of care and by building a truly local health service. From the hospital's point of view, this is only possible if five conditions are met:

Limiting the application of T2A [the tariff system] to standard, elective types of care;

Guaranteeing stable tariffs at a level which corresponds to the real costs of care;

Providing new ways of financing non-standard, emergency care, especially a complete episode of hospital care and, crucially, an annual allocation linked to activity in the hospital. This hospital-wide support would encourage professionals to organize more ambulatory care and develop aftercare by "telemedicine". An annual budget linked to activity would give doctors and paramedic teams some freedom of action while working with managers.

Maintaining in each unit a sufficient number of staff to guarantee safe and high quality care. Whenever it becomes necessary to reduce [rising] activity this should not entail an automatic suppression of posts.

Concentrating activity [on fewer hospitals] when this is relevant to the health needs of the regions concerned, while at the same time keeping the cohesion of the different medical specialties on different sites. François Hollande [past President of France] promised to abandon "T2A for every care". Emmanuel Macron [current President] has made the same promise. We MUST act now before it is too late!"


The first article:

This has never happened before. More than one thousand doctors and health service managers from all types of hospitals, local and University centres, all over France, have signed an appeal warning of the very serious situation in French hospitals, and taking aim at a system of finance, the "tarification by activity" ("T2A") in crisis and threatening the quality of care.

It is almost unprecedented for doctors and other medical personnel to rally to a single movement ["mobilisation"] with the same sense of urgency and fear, whereas under ordinary circumstances they are usually concerned with their own job and type of work. "2018 will be the year of danger and uncertainty" says an older union member. "The unions didn't start this, although they do fully support it". This letter, which is a petition, was drafted after the minister for health, Agnès Buzyn, gave an interview to Libération in December. She described without understatement the hospital crisis: " "We have come to the end of this phase and this system. With T2A the system was supposed to make public hospitals concentrate on profitable activities, believe that they are [profit-making] enterprises [...] We nearly made hospitals lose their compassion and sense of vocation by making teams believe that they should only do profitable business. Hospital teams were distressed by this sea change. And we have reached the logical end".

"Double speak"

Is T2A the mother of all evils? The hospital professionals have focused their anger on it. Invented more than 10 years ago, this system meant to finance hospitals according to their activities