Tribune of 1,000 department heads to save the public hospital, demonstrations by caregivers, wave of resignations… In recent months, the warning signals on the crisis that the public hospital is going through, put under high tension by nearly two years of epidemic, are multiplying. Budget restrictions, bed closures or lack of staff are all problems pointed out.
If the health crisis may have exacerbated some of these problems, they were already denounced by some hospital staff before the Covid. The year 2019 was notably marked by major strike movements in the hospital, in particular in the emergency room.
Franceinfo has immersed itself in data, particularly economic, to try to understand the root causes of the crisis in public hospitals. It is important to note that our analysis focuses on the operation of the hospital before the health crisis linked to Covid-19 because, since the start of the epidemic, the usual operating principles of the hospital have been put on hold to to be able to respond to emergencies.
How are public hospitals funded?
Since 2004, public hospitals have been financed by a so-called “activity-based pricing” system, also called T2A. The principle is quite simple: hospitals are remunerated according to the number of treatments. Concretely, the Ministry of Health defines “homogeneous groups of patients” who are treated for the same pathology and present the same level of severity. For each of them, it sets a tariff which corresponds to the amount collected by the hospital to treat this type of patient.
When this system was set up in 2004 in public hospitals, it succeeded a global budget which was much criticized. Each hospital had a budget based on the previous year and which varied little. This system had the advantage of offering visibility to the establishments, but it lacked the flexibility to adapt to changes in the activity. If a hospital saw its number of operations performed increase, its budget did not change accordingly. The T2A system was therefore introduced to correct this problem.
The other, more controversial feature of the T2A is that it places the public hospital in a logic of profitability which obliges hospitals to be more efficient by optimizing their expenses. Under the old system, if one establishment spent more than another for the same activity, it was not sanctioned since its larger budget was carried over to the following year. Conversely, in the activity-based pricing system, if an establishment spends more than the fixed rate, it will find itself in deficit and is therefore encouraged to save money.
How is their budget defined?
Thanks to a tool called “Ondam”. This acronym may mean nothing to you, yet it is essential to understanding hospital financing. This is the‘National health insurance expenditure target, i.e. an amount set each year by the Social Security financing bill (PLFSS) which is then voted on in Parliament (the financing law) and which defines the amounts not to be exceeded for the coming year. Ondam sets separate budgets for city care (the activity of liberal health professionals) and health establishments (public, private or medico-social).
Over the past ten years, the amount set by the Ondam Hospital is constantly lower than the budget that hospitals would really need, which means that they have to save money. For example, for the year 2018, the Social Security department estimated that, if no measures were taken, the hospital budget would increase by 4%, due in particular to the increase in activity and the Aging of the population. But in a logic of budget control, Ondam had set the objective of increasing the budget by only 2%. This difference between the natural increase in the budget and the objective set represents just over one and a half billion euros that year. These are therefore savings that must be made in hospitals during the year.
These savings requested from the hospital are more and more significant over the years. Over the period 2011-2015, 500 million euros in savings were requested annually, while between 2016 and 2020, this sum exceeds 900 million each year, even reaching more than one and a half billion euros in 2017 and 2018.
How are budget restrictions enforced?
To achieve these savings, the Ministry of Health uses the activity-based pricing mechanism (T2A) described above: if, as in 2018 for example, the ministry estimates that hospital activity will increase by 4% but that he wants to limit the increase in expenses to 2%, he will lower the prices of operations. This means that an establishment having carried out the same activity from one year to the next will receive less money since the amounts of certain operations have been lowered.
“This does not allow for visibility, and the hospital’s remuneration therefore no longer corresponds to its activity, whereas this is normally the principle of the T2A system.“, denounces to franceinfo Emmanuel Rusch, president of the French Society of Public Health (SFSP) and hospital practitioner at the CHU of Tours. Zeynep Or, member of the Paris Dauphine economics laboratory and specialist in health issues, points to a vicious circle induced by these price reductions: “To compensate for the reduction in Ondam’s tariffs, which are causing them to lose budget, establishments are seeking to increase activity. But this increase in activity will itself push Ondam to lower tariffs further so as not to exceed budgetary targets.
To save money, have hospital beds been closed?
Since 2000, more than 80,000 public hospital beds have been closed. This represents a 25% drop in the number of beds in twenty years. But for Zeynep Or, this figure should not be seen as the most essential indicator: “Bed closures are not a problem in themselves: techniques are evolving and make it possible to stay in hospital for less time, and that’s a good thing. People rarely want to stay in hospital. It’s true that “you have to have a margin in the number of beds in the event of a health crisis like the Covid, this was a problem among the British, who were on a tight schedule. But in France, we have twice as many hospital beds per inhabitant that across the Channel“.
It is also important to note that while hospital beds are down, this is not the case for resuscitation or intensive care beds, which have been particularly in demand since the start of the Covid-19 pandemic. Between 2013 and 2019, their number increased by just over 5%, according to data from the Drees (Research, Studies, Evaluation and Statistics Department).
>> How France has lost nearly 80,000 public hospital beds in twenty years
Emmanuel Rusch is more cautious, considering that the ambulatory shift, that is to say the increased use of city medicine to avoid nights in the hospital when it is not essential, “maybe a good thing, but you still have to have the means on an outpatient basis, which is not always the case where I practice, in Centre-Val de Loire, for example”.
Are French caregivers less well paid than in our neighbors?
The increase in remuneration is a long-standing demand from hospital staff, especially during the caregivers’ strike in 2019. In detail, the latest figures provided by the DREES, which date from 2018, show that the median salary of doctors at the public hospital reached 5,535 euros net per month. This median salary was just over 2,258 euros net for nurses, and only 1,774 euros net for caregivers.
To give an order of magnitude, the latest figures from INSEE estimate the median salary of French employees for a full-time equivalent at 1,940 euros. The caregivers are therefore clearly below. Nurses are mostly above, but it should be remembered that this is a job requiring at least three years of study after the baccalaureate to be able to exercise it. And the working conditions of caregivers and hospital nurses are also specific, with, for many of them, the need to sometimes work at night and on weekends, with extended hours.
For Zeynep Or, the problem of remuneration therefore mainly concerns nursing staff, nurses and nursing assistants, who represent just over 56% of the workforce at the public hospital: “Their salaries did not keep up with inflation, with the repeated freezing of the index point, as for all civil servants. So there was a drop in purchasing power for them.”
The comparison with our European neighbors actually shows that French hospital nurses are the worst paid. In purchasing power parity, OECD figures show that a nurse thus earns 20% more in the United Kingdom, 26% more in Germany and even 40% more in Belgium.
Since then, the Ségur de la santé, which took place in the spring and summer of 2020, has been there, granting significant salary increases for hospital staff. But even with this increase, of the order of 15% for nurses, France remains clearly behind most of its neighbors, only exceeding Italy.
Are the numbers down?
Data from the DREEs make it possible to observe the evolution of the workforce in public hospitals over the past 15 years. If, between 2004 and 2014, the workforce increased overall, by around 1% per year on average, a very slight decline has begun since 2015.
Zeinep Or points out, here again, a particular problem concerning the nursing staff. “The medical staff [médecins, chirurgiens…] increased, on the other hand the number of non-medical caregivers, that is to say nurses and nursing auxiliaries, has clearly decreased. This means that in addition to the decline in their purchasing power, the workload per person has increased for caregivers.”
The case of qualified nurses illustrates well, according to her, the problems of the public hospital: “There is a particular difficulty in recruiting more qualified nurses, because there are few recognized specializations for nurses. And even when they exist, these specializations bring almost nothing in terms of salary and they are not really given more responsibility or autonomy.”
These recruitment difficulties lead to forced closures of beds, for lack of caregivers to take care of them. At the end of October, the Covid-19 Scientific Council estimated that this concerned up to 20% of hospital beds.
I was too lazy to read everything, can you give me a summary?
For at least ten years, budgetary restrictions have been imposed each year on the hospital within the framework of the Ondam (National Health Insurance Expenditure Objective). These savings are made through the activity-based pricing system (T2A), in force in public hospitals since 2004 and which places health establishments in a logic of profitability.
The 80,000 public hospital beds closed for twenty years are the result of budgetary restrictions and the desire to move towards a health system that is less centered on the hospital. The lack of resources has also had an impact on the salaries of hospital staff, with French nurses earning, for example, less than in our European neighbors.
These low salaries, combined with difficult working conditions and a lack of recognition, have made hospital jobs unattractive. The hospital is therefore currently faced with difficulties in recruiting nursing staff, in particular nurses or nursing assistants.