Dr Frédéric Paing is a general practitioner and an active member of the “Santé en danger” collective.
Jean-René Binet is a professor of law, and LR mayor of Hauteville-sur-Mer.
A bill "against medical deserts" was registered with the presidency of the National Assembly on January 17, 2023. Such an initiative may seem to be going in the right direction as it is difficult to challenge the difficulties of access to health care. our fellow citizens: everyone has experienced it personally or in their circle.
This is the observation made by local elected officials, alerted by their constituents who are legitimately worried about their health.
Some parliamentarians, in haste, then propose solutions which do not always have the obviousness attributed to them.
This is the case with this proposal, the content of which is unfortunately not such as to resolve the problem and which, moreover, is part of a particularly oppressive context for doctors.
This lack of foresight is
Read also“The malaise of doctors”
The bill sins first by a lack of vision.
Its structuring idea can indeed be summed up as follows: to allow doctors to settle in under-dense areas, it suffices to increase the constraint or the incentive to settle there.
Such an idea could perhaps work if there were over-dense territories from which the system would then organize a redirect to balance everything out.
However, even if the densities vary from one territory to another, making it possible to affirm a ratio of 1 to 3 of medical density between the Hautes-Alpes and the Eure - departments with singularly different geographies - the reality is above all that 87% of the French territory is under-equipped with general practitioners.
In addition to the importance of the proportion of under-dense territories,
unfortunately, this does not mean that the remaining 13% would be over-endowed: the ratio between “over-endowed” areas and medical deserts is only 1.7.
The reality is that the shortage is omnipresent: Fréjus, Orléans, Seine-Saint-Denis, Manche, Médoc and so many other territories are looking for general practitioners.
It should therefore be borne in mind that only 9 to 13% of graduates of a promotion (according to the various figures) settle in liberal practice in general medicine and that a restrictive measure affecting a modality of exercise has never was a factor of attraction.
Thus, the measures envisaged will lead many graduates to flee liberal medicine where, on the contrary, they should be encouraged to embrace this mode of exercise.
Although working with APNs appears desirable and necessary, it can only be conceived as a complement to the action of the general practitioner.
Jean-René Binet and Frédéric Paing
The bill then sins by an excess of incantations.
She thus evokes the restoration of the permanence of the care while this one never ceased to exist since it currently covers 95% of the territory.
She welcomes the removal of the
numerus clausus
as a major step forward.
However, if it is obviously a good idea, it has been burdened (voluntarily?) with a
numerus apertus
which still restricts access to medical studies far too much, which will result in an insufficient number of doctors trained by 2030, wrongly announced as a period of thinning;
we will only find in 2037 a number of doctors comparable to 2010 (which was already not flamboyant) while, during this time, the population will have greatly increased or aged.
Finally, it advocates direct patient access to Advanced Practice Nurses (IPA) as a good solution to relieve general practitioners of certain medical tasks.
However, if the work with the IPA appears desirable and necessary, it can only be conceived in addition to the action of the general practitioner within the framework of a delegation of tasks implying that the responsibility always lies in
fine
to the doctor.
However, the spirit of the bill, taking up the idea of the "Rist" bill, is, on the one hand, to allow direct access to the IPA, that is to say without addressing prior to the attending physician.
Read also“Let’s remember: there was a time when doctors were accused of being too numerous!”
On the other hand, it would dedicate to the benefit of the IPA the competence of the first prescription.
We can only be concerned that this skill, which is only acquired in the medical course after a long training in physiopathology and pharmacology, from the seventh year and under the responsibility of a senior doctor, would be granted to IPAs after a State Registered Nurse (IDE) diploma coupled with a short and particularly poor training in pharmacology.
It would therefore not be a delegation of tasks but a transfer of skills, the responsibility for which also lies partly with the attending physician for the simple reason that the APN would have completed the shared medical file of the patient!
In addition to the thorny problem of liability raised,
it should be added that the skills of IPAs are not currently validated.
Indeed, law n° 2021-1754 of December 23, 2021 on the financing of Social Security provided for IPAs, on an experimental basis, for a period of 3 years, in 3 regions, the possibility of certain prescriptions for which a evaluation with a view to possible generalization.
We are not at the end of the 3 years and the bill is therefore freed from this experiment, without regard for patient safety.
possible generalization.
We are not at the end of the 3 years and the bill is therefore freed from this experiment, without regard for patient safety.
possible generalization.
We are not at the end of the 3 years and the bill is therefore freed from this experiment, without regard for patient safety.
Worse, they brought out another, unexpected: the disgust, even nausea, of overwhelmed doctors, already giving without counting.
Jean-René Binet and Frédéric Paing
In addition to its content, the bill is part of a particularly trying context for general practitioners: the accumulation of appeals to 49-3 for the PLFSS in the fall, the Rist bill in the process of parliamentary shuttle, the proposals of President Macron during his wishes for Health on January 6, 2023 (relayed by Thomas Fatôme, director of the CNAM) in the form of a regional commitment contract (real straitjacket restoring a general practitioner who can be cut and worked at will) .
Neither these elements nor this new bill solve the problem of access to healthcare for our fellow citizens.
Worse, they brought out another, unexpected one: the disgust, to the point of nausea, of overwhelmed doctors, already giving without counting, designated as guilty and punished (in the form of very constraining if not coercive measures) by the political representatives of the incompetence of their predecessors.
Thus, for the past few weeks, the will of an increasing proportion of general practitioners to flee liberal medicine has been reinforced every day: interns are considering another specialty, many substitutes declare that they have given up their possible installation plans, the oldest are anticipating their retirement, while many of the others are organizing their retraining.
Indeed, vacant salaried positions abound and these punitive, coercive,
threatening are contrary to what should be done.
To denigrate, to accuse, to make those who hold on at arm's length feel guilty (for 20 or 30 years for some, at the cost of many personal sacrifices that everyone would now consider scandalous for themselves) the city health system feeds the ferments of the worsening of the health disaster.
Indeed, Health stands on two legs: the hospital which is in a state of acute ischemia and the city which is desperate to amputate.
Inevitably, health will therefore end in short pants!
at the cost of many personal sacrifices that everyone would now consider scandalous for themselves) the city health system feeds the ferments of the aggravation of the health disaster.
Indeed, Health stands on two legs: the hospital which is in a state of acute ischemia and the city which is desperate to amputate.
Inevitably, health will therefore end in short pants!
at the cost of many personal sacrifices that everyone would now consider scandalous for themselves) the city health system feeds the ferments of the aggravation of the health disaster.
Indeed, Health stands on two legs: the hospital which is in a state of acute ischemia and the city which is desperate to amputate.
Inevitably, health will therefore end in short pants!
Despite the very degraded situation, we should not give in to panic and consider realistic, short-term, very short-term solutions since we are already in the wall.
Here are some leads based on the observation, accepted by all, that there are not enough doctors and will not be there for 10 or, more likely, 15 years, without any absolute certainty.
It is also important to value the work done by current general practitioners, by raising the price of the consultation.
Jean-René Binet and Frédéric Paing
First, while we struggle to relieve doctors of medical tasks (transfer of skills to APNs without delegation), multiple meetings, management of a treating medical team within the framework of SISA (interprofessional ambulatory care ) or CPTS (professional communities of health territories), they claim to be relieved of administrative tasks.
A measure already initiated goes in this direction: the system of medical assistants promoted by the CNAM and which President Emmanuel Macron calls for strengthening.
However, before going further in this direction, it is necessary from now on, in consultation with the doctors, to list the useless administrative work and to delete it purely and simply.
In addition, it seems imperative to develop the
financial assistance for these jobs (which involve paying salaries, charges, renting an office that must also be equipped, and additional secretarial time because this hiring is also intended to increase the patient base of doctors);
finally, you have to have the honesty to explain to patients that the time for “singular consultation” with your doctor will be reduced.
Furthermore, it is also important to value the work done by current general practitioners, by raising the price of the consultation, to boost attractiveness and the desire to settle rather than lengthen the list of repulsive constraints.
For the record, approximately 40,000 general practitioners are not installed, which constitutes a considerable breeding ground for really reducing situations of under-density.
Finally, it is also necessary to value the colossal real, existing, current work, which works, of the couple general practitioner-liberal nurse, without encumbering it with administrative organizations (SISA, CPTS or other Théodule committees): this involves remuneration for time informal spent daily solving the problems of complex patients and this also involves a revaluation of the nursing act.
