New regional health governance

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Featured in half-yearly report: G-politik in Industrieländern 12

Abstract

The Minister of Health Mme. Bachelot presented to the government a reform package which would transform radically the organization and provision of hospital care in France, once adopted. The reform includes a provision for a new governance structure with greater deconcentration of financing and negotiation powers.

Purpose of health policy or idea

After months of preparation and debate, Mme. Bachelot presented last week a controversial draft law package which aims to improve the supply and coordination of health care at the regional level. To do this, the text suggests modifying not only the organisation and governance of hospitals but also of ambulatory care and medico-social services. It consists of four major chapters:

1. More regional governance.  One key measure developed in draft law is the creation of new "Regional Health Agencies" (RHA) which have been on the political agenda for a long time. Along the lines of a "one-stop-shop", these new agencies will bring together, in one entity, seven public instances (including public health insurance funds) which are currently responsible for organising and financing health care at the regional level. They will have the mission to set up regional level objectives to assure fair access to care, improve coordination between hospital and ambulatory care providers, and enhance quality and prevention. Each hospital will have to sign an annual contract with RHAs to secure funding. The ultimate idea is to make the RHAs responsible buyers contracting with individual hospitals rather than being simple payers. One controversial aspect is that RHAs could also contract with private hospitals to carry out what is considered as "public missions": providing emergency care, research, etc.
2. Modernising the organisation of health care institutions. The law aims to create new juridical entities called "local hospital communities" (communités hospitalières de territories, CHT) by regrouping a range of small and big hospitals on the basis of complementarity of competencies. The idea is to concentrate complex interventions in high volume hospitals and transfer small local hospitals to take care of less complex medical and medico-social care. In principal, hospitals within a CHT will be able to share the patients as well as their health care resources. For example, a small hospital could transfer its most severe patients to a bigger one, but also a bigger hospital could lend a specialist to a smaller hospital for a couple of days a week. Following the storm of reactions from hospital federations and unions, the Minister of Health assured that there will not be any hospital closures.  
   Moreover, the rules of management in public hospitals will be simplified and hospital directors will have real autonomy in management with better defined objectives and result-based evaluation. One novelty is that they will have more flexibility in recruitment decisions with the possibility of establishing part time contracts with private practitioners. The modes of remuneration for physicians will also be more flexible, with the idea of introducing performance based payment. In turn, hospital directors will sign annual contracts with the RHA setting out specific activity and quality objectives.
3. Improving territorial access and care quality. The reform also aims to redefine the organisation of ambulatory care which has been treated as a separate issue until now. For the first time, the term "primary care" (which did not exist in French) will appear in the public health code. The role of GPs is defined in the law with the aim of enhancing the role and status of generalists. Measures are also proposed to develop group practice. The draft law also tackles the issue of the unequal geographic distribution of physicians which has been a chronic problem over the past years due to the "sacrosanct" principle of "freedom of installation" for physicians. Given the sensitivity of the subject, the text is rather timid, but proposes to introduce financial punishments to discourage physicians from installing their practices in areas with high doctor density. There are no specific measures and the responsibility for this has been given to the future RHA. There are also proposals to improve after-hour care at the regional level to relieve the congestion at hospital emergency services.
4. Improving preventive policy. The draft law comprises a chapter on improving prevention policy. This chapter, initially with high ambitions has been pruned considerably between successive versions. One concrete measure will be the restriction of alcohol and tobacco sales to young people (under 18 years old).

Main points

Main objectives

Major objectives stated by the Minister are:

• To enhance the accessibility and quality of hospital care;
• To encourage coordinated care for patients by facilitating the cooperation between hospitals, primary and social care providers (such as retirement homes)
• To improve the efficiency of health care spending

Type of incentives

Both regulatory and financial

Groups affected

Public and private hospitals, hospital personnel, all physicians, patients, regional and national representatives of the health insurance funds, regional hospital agencies, other regional instances regulating hospital care

Innovationsgrad	traditionell		innovativ
Kontroversität	unumstritten		kontrovers
Strukturelle Wirkung	marginal		fundamental
Medienpräsenz	sehr gering		sehr hoch
Übertragbarkeit	sehr systemabhängig		systemneutral

Political and economic background

The major focus of health care policy in the past 20 years in France has been controlling the public health deficit. After decades of successive reform plans which only proposed short term remedies (aimed at mostly restricting demand), the necessity of more structural reforms has been recognised. The introduction of new financing modes for hospitals (see HMP 2005/1, Hospital payment reform) has also accentuated the need for change in governing hospital sector.

The draft law represents the structural changes which were necessary to complete the previous reforms in the hospital sector (see HMP 2007/1, Hospital 2007).

Several official reports have been prepared for the government during 2008 which have pointed out that several major issues in the hospital sector are not independent from those in the rest of the healthcare system. In particular, the following have been identified as being major problems both in terms of quality of care and cost control:

• Compartmentalisation of health care providers and financers
• Lack of articulation between central and regional levels
• Separation between the management of health care provision and the management of health care expenditure
• Separation between ambulatory, hospital and social care

Purpose and process analysis

Current Process Stages

	Idee	Pilotprojekt	Strategiepapier	Gesetzgebung	Umsetzung	Evaluation	Veränderung/Richtungswechsel
Implemented in this survey?

Origins of health policy idea

The idea of creating regional health agencies, with an enlarged role of controlling both inpatient care and outpatient care has been around for a long while, but somewhat has been difficult to implement.  Nicolas Sarkozy had announced in his presidential programme that he will introduce regional health agencies and "modernise" the hospital sector with more liberal rules. He asked Mme. Bachelot to prepare the reform plan.

Initiators of idea/main actors

• Regierung

• Leistungserbringer

• Kostenträger

• Patienten, Verbraucher

Approach of idea

The approach of the idea is described as:
new:

Stakeholder positions

The initial reactions of all parties were scepticism and strong criticism.

Even before the beginning of consultations with different stakeholders, which took place mid-September, the draft law has been modified several times. A preliminary version of the law has been obtained and published by the press at the beginning of September triggered an avalanche of reactions. The Minister revised her copy within a week.

Most of the stakeholders were opposed to the project for very different reasons. Hospital closure is a very sensitive issue and there have been several demonstrations against the reform which is seen as the "end of the small hospitals". Most of the public hospital personnel (unions) are also against the reform which introduces flexibility in pay and new management rules. Some fear that public hospitals will suffer under the new system where private hospitals can attract more public funds.

Physician unions were very firm about their right to keep "freedom of installation".

Several guarantees were given during the consultation period to calm the spirits, in particular to small hospitals to assure that there will be no hospital closure, to physicians about respecting their freedom of installation, etc. Therefore, after the consultations all the stakeholders' position is rather perplex.

One major issue, still under negotiation is who will have how much power in the new regional health authorities.

The council of national sickness funds (CNAMTS) which consist of the representatives of insured employees, employers and complementary insurance funds, and is consulted on any text having an impact on health insurance has voted against the draft law (after consultations). They denounce that the consultative process was a pure formality and regret the lack of dialog and debate on the draft law. In particular, they are worried about how much power they will have within the RHAs and the risk of increased state control, given that the directors of RHA will be nominated by the council ministers (cabinet).

On the other hand, private non-profit insurance funds try to obtain a seat in the supervisory instance which will control RHAs' policies.

Actors and positions

Regierung
Minister of Health	sehr unterstützend		stark dagegen
Leistungserbringer
Public hospitals	sehr unterstützend		stark dagegen
Private hospitals	sehr unterstützend		stark dagegen
Physicians	sehr unterstützend		stark dagegen
Kostenträger
National sickness fund	sehr unterstützend		stark dagegen
Complementary funds	sehr unterstützend		stark dagegen
Patienten, Verbraucher
Patient associations	sehr unterstützend		stark dagegen

Actors and influence

Regierung
Minister of Health	sehr groß		kein
Leistungserbringer
Public hospitals	sehr groß		kein
Private hospitals	sehr groß		kein
Physicians	sehr groß		kein
Kostenträger
National sickness fund	sehr groß		kein
Complementary funds	sehr groß		kein
Patienten, Verbraucher
Patient associations	sehr groß		kein

Positions and Influences at a glance

Adoption and implementation

Initially the parliamentary debate was supposed to take place in October/ November 2008, after several iterations, it is now scheduled for the beginning of January 2009. But there will be an "accelerated" discussion at the parliament, which reduces the possibility to reject most of the acts. This is a specific procedure used for decisions deemed "urgent", and limits the parliamentary discussion to two weeks.

The Minister allows at least a year for producing all the legal texts necessary for implementation and for preparing the ground. If all goes well, the RHAs will become operational in 2010.

Monitoring and evaluation

There is a provision for a supervisory council (Conseil de surveillance) which will monitor and prove the strategic plans, yearly projects and financial means of each RHA. The council will consist of state representatives, members of local representatives of sickness funds, representatives of local authorities and patients as well as a number of qualified persons. It will evaluate yearly the results achieved by RHA and will approve its funding.

Moreover, there will be a high level "Strategic health council" which will assure the coherence of regional policies at the national level. This council will bring together in particular several ministers (Minister of health, elderly, Minister of finance and social security) and the national representatives of sickness and long term care (dependency) funds.

Expected outcome

This reform will have a fundamental impact on the organisation, provision and financing of hospital care in France once implemented.

 Most of the measures proposed correspond to long-waited structural changes for strengthening regional governance, integrating the management of hospital, ambulatory and social care, emphasizing the importance of primary and coordinated care in the system.

While the principles are sound, the expected impact of these reforms on equity of access, quality and efficiency of care will depend on how they are implemented; in particular how much power and resources the RHAs will actually have and how they will play their role of responsible buyers.

 Above all, the law needs to be voted as it is in the parliament, which will not be an easy exercise. It risks to be substantially watered down in the process of negotiation with different parties.

References

Sources of Information

"Présentation du projet de loi "Hôpital, patients, santé et territoires », 22 octobre 2008

www.sante-jeunesse-sports.gouv.fr/IMG//pdf/Dossierdepresse.pdf

Rapport de la commission de concertation sur les missions de l'hôpital, présidée par M. Gérard Larcher

www.sante-jeunesse-sports.gouv.fr/IMG//pdf/rapport_Larcher_definitif.pdf

Author/s and/or contributors to this survey

Or, Zeynep

Empfohlene Zitierweise für diesen Online-Artikel:

Or, Zeynep. "New regional health governance". Health Policy Monitor, October 2008. Available at http://www.hpm.org/survey/fr/a12/2