“Faced with compressed salaries, frantic rhythms, material difficulties in services where there are not enough caregivers (…) the hospital has become the place in which all the difficulties are concentrated.” Emmanuel Macron thus announces his diagnosis, before prescribing a “emergency plan” for the hospital, from Epernay (Marne) on November 14, 2019. The president is trying to contain the bleeding: caregivers leave the public hospital by the dozens. Those who remain are in the street, that Thursday, to demand more resources.
The plan supposed to restore“oxygen” in the hospital, presented a few days later, did not satisfy the health professionals. Hundreds of department heads resign from their administrative functions in January 2020 to make the government understand that its measures are insufficient. Two months later, France is confined, the hospital must face an unprecedented health crisis with tight resources.
Since the diagnosis of 2019 and the Ségur de la santé the following year, has the executive succeeded in treating the ills of the public hospital?
A hard-negotiated salary increase
For some it was “the emergency” of the Ségur de la santé, started on May 25, 2020. To the 19 billion euros of investments promised over five years to “Improve the care of patients and the daily life of caregivers”are added nearly 10 billion euros per year to finance a “increase of 183 euros net per month for social and medico-social staff in public hospitals”.
Ségur first acts on an envelope of 8.2 billion euros for this purpose. Once signed, the “exceptions fall”, regrets, however, Thierry Amouroux, spokesperson for the national union of nursing professionals (SNPI). Some health professionals will not be eligible. In May 2021, the government therefore promises an extension of 500 million euros per year for the “forgotten Ségur”. The increase of 183 euros will be extended to staff working with disabled patients and in home nursing services. Eighteen months later, thousands of other social workers, such as specialized educators, still consider themselves “forgotten”.
Midwives are also demanding that their status be upgraded. In November 2021, the government promises them 500 euros net per month of increase (including the 183 euros of Ségur), applicable from February 1, 2022. “But nothing has come out yet”, assures Caroline Combot, secretary general of the National Organization of Midwifery Unions (ONSSF). In the absence of a published decree, the announcement remains as a promise. Contacted, the Ministry of Health did not respond to requests from franceinfo on this subject.
These revaluations have sometimes highlighted inequalities. The announcement of a bonus of 100 euros for nurses in critical care services, at the end of December 2021, did not concern caregivers, who nevertheless work in pairs with nurses. “There is bound to be resentment when you give to some and not to others, when they are in the same service”argues Thierry Amouroux.
Recruitment promised, but difficult to achieve
In the conclusions of Ségur (PDF), the government plans to recruit 15,000 caregivers. In details, “7,500 job creations and 7,500 recruitments to vacant positions”, specifies, Zaynab Riet, general delegate of the Hospital Federation of France (FHF). For this, a diagnosis will first be carried out in each hospital establishment in order to take stock of the “staff situation”.
It remains to find candidates. Because the hospital does not dream and suffers on the contrary from a haemorrhage of doctors, nurses, caregivers, who leave, exhausted. “Nobody disputes that the Ségur is useful. But we have to look at the reality! Has this made it possible to retain and bring caregivers back to the hospital? No”slice Bernard Jomier, environmental senator and president of a commission of inquiry into the public hospital.
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The number of recruitments announced also seems derisory in view of the vacancies. Just for nurses “we went from 7,500 vacancies in June 2020 to 34,000 in September 2020”, explains Thierry Amouroux. The SNPI estimated the shortage at 60,000 nurses in December 2021. In practice, the difficulties in recruiting “are such” that in the current context, the FHF estimates that there is a lack of between 4% and 5% of nurses (not counting specialist nurses) and around 2.5% of nursing auxiliaries, i.e. around 25,000 paramedics.
More places for health students
In addition to the abolition of the numerus clausus in 2019, for the very selective competition at the end of the first year of medical studies, the Ministry of Health proposes to open up more places on the Parcoursup platform within nursing training institutes (Ifsi). In all, 200 million euros have been promised for the opening of 16,000 places by the start of the 2022 school year. (PDF) in training institutes, including 6,600 for nurses and 6,600 for nursing assistants, according to the ministry.
Opening places to students, however, does not guarantee that they will continue their careers at the hospital. In the fall of 2021, the Minister of Health revealed an alarming figure: 1,300 student nurses resigned after “their first internship at the hospital, in the midst of the epidemic wave of Covid-19”. “Caregivers express a crisis of meaning, which we perceive from the trainingemphasizes Bernard Jomier. Nursing schools are full, but right out of school, 20-30% quit. Students don’t even enter professional life.”
Hospital budgets temporarily pushed up by Covid-19
The National Health Insurance Expenditure Objective (Ondam) is the envelope voted each year within the framework of the Social Security financing bill (PLFSS). This objective sets, among other things, the budgets allocated to health establishments. From 2011 to 2020, the budget allocated to public hospitals increased by an average of 2.3% each year. Too little, according to Social Security, which estimated in 2018 that it should take 4% to cope with the increase in activity and the aging of the population.
When the health crisis hit, health spending skyrocketed. Between 2020 and 2022, the budget increased by 4.7% on average, according to Matignon, to fight against Covid-19. But the acceleration was short-lived: the overall envelope of Ondam fell by 0.6% in 2022 (PDF), “due to the drop in expenditure linked to the health crisis”. “Ondam is down 700 million euros compared to 2021, notes the senator (republican left) Marie-Noëlle Lienemann at franceinfo. The elected official is mainly concerned about the budgets to come: “For the 2023 Objective, there will be no Ségur, and it will start at 2.4%.” This is confirmed by a scenario available on the Social Security website (PDF) : for the next three years, an annual increase of between 2.3 and 2.4% is expected, as before the health crisis.
A reform of activity-based pricing in progress
Activity-based pricing, also known as “T2A”, has been the main funding method for hospitals since 2004. It consists, broadly speaking, in remunerating establishments according to the number of treatments they provide. Before that, hospitals had an annual global budget which gave them visibility, but no flexibility in the event of an increase in their activity. The T2A was supposed to make the system more flexible, but it very quickly had the effect of pushing the hospital towards a logic of profitability.
Especially since to stay within the allocated budget (the Ondam mentioned earlier), the rates for care activities have been lowered in recent years. To compensate for this price reduction, “establishments seek to increase activity”, explains to franceinfo Zeynep Or, member of the Paris Dauphine economics laboratory and specialist in health issues. A spiral that locks the hospital in its race for profitability.
With this system, “ultimately it is the prices and not the needs of the patients that determine the practice”, adds André Grimaldi, professor emeritus of diabetology at the CHU de la Pitié Salpêtrière (AP-HP) and co-founder of the Inter-hospital Collective. For him, “it is necessary to choose the mode of financing most adapted to the activity: the T2A is adapted to the scheduled standardized care (operation of the cataract or appendicitis), on the other hand, the price of day is more adapted to the palliative care of end of life”.
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During his 2017 campaign, Emmanuel Macron promised to cap the weight of T2A in hospital funding at 50%. Today, the T2A constitutes approximately 63% of the financing of public hospitals. “The objective of 50% financing at T2A is therefore already almost achieved”considers Zaynab Riet, of the French Hospital Federation.
However, it is difficult to know whether this reform, “engaged” in January 2019, according to Release, continues. It was based on a report by Jean-Marc Aubert, director of DREES, who proposed “a combined funding model”taking into account “the quality and relevance of care”. Contacted on this subject, the cabinet of Olivier Véran did not answer questions from franceinfo.
Hospital debt reduced in exchange for “transformations”
In total, the debt of hospitals was valued at 29.3 billion euros in 2019, according to the direction of research, studies, evaluation and statistics (Drees). Promised in November 2019 by the former Prime Minister, Edouard Philippe, the recovery of part of this debt was taken over and amplified in the conclusions of the Ségur de la santé, to reach 13 billion euros.
For this, the hospitals contact the ARS, submit a file and it is the ARS that assesses the amount granted. For the time being, it is difficult to assess the national balance sheet of this reform, since “debt coverage rates vary greatly, depending on the institutions and their financial situation”notes Zaynab Riet.
In addition, the debt relief of an institution is the subject of a contract, which conditions it to deep reforms, as recommended by an Igas report published in April 2020. (PDF). For each hospital, “the share of debt covered must take into account its financial situation but also its level of ambition to lead the transformations necessary to improve the supply of care in the territory”can we read there.
4,000 beds open “on demand”, but closures continue
In 2020, the health crisis forced the executive to put a number of hospital reorganization plans on hold and wait at least for the conclusions of Ségur de la santé. Following this consultation, Olivier Véran announced the creation of “4,000 beds on demand” depending on the influx of patients. The idea is to allow “establishments to adapt to seasonal or epidemic overactivity”according to the conclusions of Ségur (PDF).
However, since the start of the pandemic, beds have continued to be cut. A report by the Scientific Council deplored, in October 2021, “a significant percentage of closed beds, estimated at around 20%”, after a flash survey (PDF). And this, despite a “already significant and increasing use of overtime and temporary work”. A figure disputed by the Ministry of Health, which has requested an investigation into this subject.
On the FHF side, another flash survey conducted in November 2021 on 330 public hospitals reported 6% bed closures over the period from September to October 2021, revealed the JDD (article subscribers) in November. These closures are caused by the lack of non-medical staff (70%), the lack of doctors (60%), the duplication of rooms due to Covid-19 (24%). At the end of September 2021, the DREES had 5,758 fewer beds in 2020 than in 2019.