The heatwave episode that crosses France accentuates tensions in hospitals. But the heat wave is only an aggravating factor in a crisis which has continued to worsen, especially since the Covid-19 pandemic, and which is putting the hospital on the brink of agony: in Ile-de-France, 16% of the beds in the 38 AP-HP hospitals are closed due to lack of staff, i.e. twice as many as before the Covid! The overcrowding of the hospitals is symptomatic of the global crisis of the health system: because of medical desertification, for lack of attending physicians or specialists, many French people fall back on emergencies, which are saturated. From general practitioners to emergency physicians, including nurses in nursing homes and even to health executives, everyone is on the verge of a nervous breakdown.By Cédric Gouverneur
Created in the 1960s to help road accident victims, emergency rooms have become a receptacle for all the shortcomings of the French health system: “We have crazy, alcoholic patients who are refused by psychiatric emergency rooms,” sighs Gwendal*, an ambulance driver at the University Hospital Centre (CHU) in Rennes. “So we take them to the emergency room where they stay until they are sober. Even if there is no more room, the emergency room is obliged to accept everyone”. A social worker in a university hospital in western France, Anne* says that “doctors are fed up, they are there to treat, not to manage social and administrative problems. With constant resources but increasing demand, it’s only logical that they should be overloaded”. Overwhelmed, emergency physicians spend hours on the phone looking for beds in other establishments (See the interview with Éric Guéret, director of the documentary “Premières Urgences”). “The internal context – understaffing – and the external context – an ageing population and increasing precariousness – are becoming more and more difficult, which is having an impact on the hospital,” explains Anne. “Because of understaffing, nurses are being called back during their holidays! More and more nurses are suffering from burnout. The psycho-social risks are palpable”. The increase in administrative tasks has also made the days more difficult, while working relationships are more strained: “We have to notify the slightest action on the computer,” says Gwendal. “The use of gloves, strips, etc. is time-consuming and pointless, says the ambulance driver, except to cover himself legally in case a patient is sued for negligence. In practice, it has become a way of getting back at colleagues, in the mode ‘oh look, he didn’t do that’!” Sébastien Rétif, vice-president of the ‘executives’ category of the Union of Public Health Managers (SMPS), explains that “there is nothing more complicated than managing a constrained environment, which has to operate 24/7 with an ever-decreasing number of staff. The manager is a bit like the unit’s fireman”. The Covid crisis had “at least enabled hospitals to break down the barriers between departments, to work hand in hand, in a more fluid way”. The lesson, he believes, has not been learned: “Rigidities are back, with silos”, deplores the executive, himself a former nurse.
Embolism of the care pathway
Anne is a social worker at the hospital. Her role is to “advise patients and their families in order to facilitate their discharge plans”, she explains. “Hospitalisation is expensive, so we can’t keep people longer than necessary. This implies taking care of them outside the hospital, handing them over to the medical-social sector and to the town’s medical services. We have to do more work to find solutions adapted to the doctor’s prescription and the patient’s needs. But he no longer has enough home care workers”. Another example: “The MDPH (departmental house for the disabled) is 12 to 14 months behind in processing requests! All this causes a bottleneck in the care process”.
The overcrowding of the emergency room is partly explained by the arrival of patients who should have consulted a general practitioner: “People without health insurance come to the emergency room,” sighs Anne. “Some have incomes just above the threshold and don’t have access to complementary health insurance”, formerly known as universal health coverage (CMU). Others can’t find a GP or an appointment with a specialist. Doctor Jean-Christophe Naugrette, president of the general practitioners’ union MG France, confided to us that his profession “cannot do more. A quarter of the patients seen in the practice are already ‘unscheduled’”, i.e. patients who wake up sick and ask for an appointment the same day. “The health system is like “a house of cards that is collapsing. We sounded the alarm a quarter of a century ago! Many doctors were trained in the 1970s”, he explains: “they are now reaching retirement, which is logical”. He also points out that, “out of 90,000 GPs, only 51,000 are ‘treating’ doctors, because it is no longer attractive enough. Income in general practice is on average 30-40% lower than in specialist medicine”. A doctor will therefore often choose to extend his or her studies in order to specialise, then settle in a shimmering area (the New Aquitaine region, PACA, etc.), leaving behind rural and poorly served areas: “The number of general practitioners is falling, but that of specialists is rising”, confirms the DREES (Directorate for Research, Studies, Evaluation and Statistics), in a study on medical density updated last September. Ten million French people live in an area where access to healthcare is below average, as the Association of Rural Mayors of France (AMRF) points out on its website. Spatial and social inequalities have dramatic consequences: the wealthiest can go to private clinics. But patients – often disadvantaged – are received in emergency rooms with serious symptoms, cancers diagnosed too late, because they have not been able to consult a specialist. The DREES deplores the fact that “long delays in appointments can lead to the abandonment of care”.
One director for two sites
Dr Naugrette also points out the GPs’ working hours: “From 8 to 20 hours, five days a week, plus Saturday morning. That’s 55 hours on average, plus on-call periods. Low pay and long working hours make for an unattractive cocktail” All the more so, he adds, because “the population is older, with more chronic illnesses and multiple pathologies: the GP accompanies the great ageing process, which implies more complex and longer consultations, but paid at the same rate (25 euros) as the treatment of a simple angina”. This demographic ageing has an impact on public EHPADs, which suffer from the same ills as emergency departments, general practitioners and home care: overload, understaffing and devaluation. Estelle* is a nurse in a public EHPAD in Brittany: “There is one director and one manager for two EHPADs that are tens of kilometres apart! Look for the error… There are two nurses for about sixty residents, plus two care assistants in the morning and one in the afternoon. The only manager, who is usually present in the other establishment, delegates her tasks to us”. During Covid, the management was teleworking and the nurses were on the front line: “Confining the residents, prohibiting visits. I felt like a soldier who had to obey orders. We never got any answers to our questions”.
Despite the post-Covid “Segure of health”, the decrease in resources continues in his EHPAD: “Since 2015, the equivalent of 70% of nursing time has been cut. Time is short, what matters to the management is that the residents eat and are clean. We no longer do enough ‘evaluative collection’”, an individual questioning of each resident in order to assess their needs. “We no longer have the time, so we assess about ten residents a year, out of sixty. And to conclude: “There is not enough interaction. Some staff become abusive without realising it. When you report an anomaly to the management, nothing happens. It is only when a family complains that there is a reaction.”
How can we relieve congestion – and save! – the health care system? Faced with the red line that would constitute, for liberal doctors, the questioning of their freedom of installation, MG France calls for “restoring the attractiveness of the profession: a revaluation of fees and fixed remuneration”: longer, the consultation of elderly patients suffering from multiple and chronic pathologies would be remunerated more than the general public. The monthly bonus of 183 euros granted by the “Segure of health” was not enough to slow down the haemorrhage of nurses leaving the public hospital, who were poached by private clinics, which paid much more! The 2,200 nurses recruited in 2022 by the Public Assistance – Paris Hospitals (AP-HP, 38 public hospitals in the Île-de-France region) do not compensate for the 2,800 departures. The director of the AP-HP, Nicolas Revel, announced in Le Parisien on 13 December his intention to recruit 2,700 nurses each year, with incentives to slow down the turnover (transport subsidies, reserved accommodation, meal vouchers, etc.). It is not certain that this will be enough, as no salary increase is planned… A sign of their malaise, nurses are hardly interested in changing to hospital management: “The IFCS (health executive training institutes) are not full”, explains Sébastien Rétif, of the SMPS. The Ségur’s salary increase “was only the catching up of increases that had not been paid for years”, says the trade unionist. In such a context, “leaving one’s profession – care worker, reeducator, medico-technician… – to become a manager is not attractive”.
However, the accounting logic argues for an increase in public sector salaries: “Better remuneration for home care assistants would cost the State much less than prolonging the hospitalisation of patients because of the lack of home care”, says Anne. “However, concludes the social worker, France has the skills, the will and the multidisciplinary teams. The public hospital, she reminds us, works well with the other health actors. We know how to do this well. With additional resources, we could do better. We feel helpless”. Estelle points out that, in her double-EHPAD with only one director, “two nurses are going to leave and the management can’t find anyone to replace them. No one.”
* The first names of witnesses have been changed to preserve their anonymity.