Hospital and medical equipment planning

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

Abstract

The Ordinance for the simplification of hospital and other medical facilities planning passed in September 2003, aims at: Merge in a single tool (the regional strategic plan) the strategic planning of hospital facilities and activities which was before managed through several tools; To decentralize to the regional hospital agency almost all types of authorizations for hospital activities, facilities and other medical equipments.

Purpose of health policy or idea

The reform passed in September 2003 aimed at simplifying and harmonizing the planning of hospital activities and facilities and the planning of medical equipment. The objectives of the reforms were:

• To merge in a single planning tool (the regional strategic plan) the strategic planning of all hospital facilities and activities, which was previously managed through several planning tools (One defining the "needs" of the region, one defining a strategic plan for medical activities in the region);
• To decentralize almost all types of authorizations for hospital facilities, medical equipments and hospital activities at the regional level by reinforcing the competencies of the regional hospital agency (ARH).

The expected outcome is to simplify the process of planning and allow greater flexibility for the regional agencies in the use of the planning tools.

This reform is part of a more ambitious plan "Hospital 2007", announced in November 2002 par the Minister of Health.

Main points

Main objectives

The main objective is to simplify hospital planning process, by unifying the several existing planning tools and by delegating to the regional hospital agency the competency to authorize or refuse the installation of new hospital facilities, new hospital activities or new medical devices.

Groups affected

Public and private Hospitals., Regional hospital agencies, Private providers of medical equipments, facilities and inpatient care

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral

Political and economic background

The principal aim of the reform is to simplify the process for regional planning of medical and hospital equipment to make it more responsive. Before this reform, hospital planning rested on three different tools:

• The medical chart (carte sanitaire, created in 1970) divided all the country in 256 health sectors, for which targeted levels of equipments were set, within a range defined by the Ministry of Health. The medical chart used to define "quotas" for the installation of facilities (beds or places) for hospital care (acute care, psychiatric care and rehabilitation), for certain medical equipment (MRI, scans, radiation machine) and for costly activities (neurosurgery, heart surgery, organs transplantations …). The medical chart had to be approved at the regional level by the director of the ARH.
• Since 1991, the regional strategic plan (SROS: Schéma régional d'organisation sanitaire) has been used to organise hospital activities on a basis of a more qualitative approach. This plan sets out strategic goals for the evolution of the regional provision of hospital care over a 5-year period and suggests re-organization of hospital supply. This plan constitutes then a reference for the ARH, which has to grant authorizations for the development of medical and surgical hospital activities.
• The organization of psychiatric care was planned through another specific plan.

A system of "authorizations" completed these documents: the director of the ARH has to formally authorize (or refuse) the installation of new hospital facilities (inpatient beds and places for hospitalisation at home or ambulatory surgery), new hospital activities and new medical equipment. For some equipments and activities (radiotherapy, MRI, neurosurgery cardiac surgery, lithotripty), the authorizations were given at the national level by the Ministry of Health.

Authorizations were delivered for different periods: 5 years for hospital activities, 7 years for medical equipments and 10 years for hospital facilities (beds and places). This system was criticized for its complexity and lack of responsiveness. So, in November 2002, the government announced the simplification of the planning process as part of a larger reform, planned for the 2002-2007 period "Hospital 2007".

The new reform, passed in the Ordinance of the 4th of September 2004, introduced several changes.

1. The SROS is from now on the central tool of the regional planning and will deal with all the domains previously handled by the medical chart, which is cancelled.
2. The quantitative norms that existed for each discipline of hospital activity (medicine, surgery, obstetrics, psychiatry, intermediate care and long term care) in terms of bed/population ratios for inpatient care or place/population ratios for hospitalisation at home or ambulatory surgery are suppressed. Nevertheless, an annex of the SROS will define quantitative norms to limit the level of equipment or activity in a given territory.
3. The previous geographical division into sectors is abolished. The ARH are now invited to design relevant territories for different activities.
4. More competencies have been delegated to the ARH to authorize the installation of medical equipments and/or activities. Only a few equipments and activities will come under inter-regional or national planning (the list will be published by ministerial decree later).

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Origins of health policy idea

France has a long tradition of planning of health equipments and activities. This policy nevertheless encounters some opposition, essentially coming from the private hospital sector.

The idea of a total liberalization of the installation of medical equipments has been actively promoted by these stakeholders and the present government was rather favourable to this solution.

It can be assumed that health authorities in charge of the organization of health care (a Directorate of the Ministry of health) have put some pressure on the government to prevent a total liberalization.

Stakeholder positions

The idea seems to be widely accepted by a majority of stakeholders: public hospitals, ARH, and the Directorate for the organization of health care of the Ministry of Health.

Stakeholders from the private hospital sector are not satisfied by the compromise between the previous system and the total liberalization they were expecting. They especially criticize:

• the re-introduction of quotas (namely suppressed with the medical chart) in an annex of the SROS
• the definition of "territories" for each type of equipment and activity by the ARH.

However, this part of the Ordinance is not the more controversial part. Another part, making easier the participation of the private sector in hospital investment, encounters a wide opposition from the left wing parties.

Influences in policy making and legislation

There are two pieces of legislation:

The Law of the 2nd of July 2003, empowering the government to adopt measures to simplify the French Law by ordinance (available at http://www.legifrance.gouv.fr/WAspad/UnTexteDeJorf?numjo=FPPX0300014L)

Ordinance of the 4th September 2003 (available at http://www.legifrance.gouv.fr)

Adoption and implementation

This reform should be implemented without difficulties, all actors of the new planning system are already in place and familiar with planning tools used.

Even for opponents, favourable to total liberalization, the reform does not damage their situation in comparison with the previous situation.

Monitoring and evaluation

There is no foreseen mechanism to assess the impact of this reform.

Expected outcome

The expected outcome is to simplify the planning process to make it more responsive. In the new context, regional hospital agencies will have to manage local pressure for the installation of equipments and activities, and will no more have the possibility to put forward a "maximum level of equipment" fixed by the government to resist to this pressure.

The impact on geographical equity should be monitored.

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high

References

Sources of Information

« Le pilotage de la politique hospitalière », in Court of Accounts "Annual report to the Parliament on Social security", September 2002 (http://www.ccomptes.fr/Cour-des-comptes/publications/rapports/secu2002/introduction.htm)

"Hôpital 2007": plan announced by the Ministry of Health in November 2002 (available at http://www.sante.gouv.fr/htm/dossiers/hopital2007/)

Legislative documents about the Law of the 2nd of July 2003, empowering the government to adopt measures to simplify the French Law by ordinance http://www.senat.fr/dossierleg/pjl02-262.html)

Ordinance of the 4th September 2003 (available at http://www.legifrance.gouv.fr)

Author/s and/or contributors to this survey

Valérie Paris, Dominique Polton

Suggested citation for this online article

Valérie Paris, Dominique Polton. "Hospital and medical equipment planning". Health Policy Monitor, October 2003. Available at http://www.hpm.org/survey/fr/a2/4