Reorganization of after hours ambulatory care

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

Abstract

Over time, the after hours provision of ambulatory care by private practice physicians became somewhat problematic in some parts of France. Some local and rather innovative solutions had been initiated, but the government had to address the issue at the national level and issued two decrees since September 2003.

Purpose of health policy or idea

The after hours provision of ambulatory care by private practice physicians, once organized rather spontaneously on a professional basis, became problematic over time, as a consequence of the increasingly unequal distribution of physicians over the territory combined with changes in their expectations in terms of working conditions.

Tensions between the medical profession and public authorities focused on this issue in the year 2001. After a series of difficult negotiations, a new regulation was set up in September 2003 to ensure that patients over the country can receive care after hours. While this regulation remains to be fully implemented, local initiatives (like 'on-call houses' see 5.1 for definition) have emerged that aim at achieving what is known as "permanence des soins", the provision of non-elective ambulatory care, mainly by GPs, around the clock, all year long and in all places.

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

New forms of organization emerged from local initiatives, which is not really a tradition in the French health care system. While the national debate was very conflictual, the Descours mission reached a compromise among actors who had strongly opposed initial views, but the conflicts could start again if some issues are not solved.

Political and economic background

Until 2003, the after hours provision of care was a de facto organization set on a voluntary basis by the medical profession. This system was rooted in the Article 77 of the medical deontology code which stipulates that it is every physician's obligation to participate in the night and day stand-by duty.

This system was progressively undermined by a shift in the professionals' expectations in terms of working conditions and by growing difficulties to set on-call rosters up, in particular in rural areas of low medical density.

In an attempt to solve the problem, some innovating systems were experimented at the local level. For instance in some regions, "on-call houses" (maisons de garde) were organized by private practice physicians.

At a more global level, at the end of 2001, generalists went on strike arguing that the system was badly organized, exhausting and that, regarding this issue but also more generally, their efforts were under appreciated (in professional as well as financial terms). The strikes lasted at least 5 months and first consisted in refusing night duty and later expanded to include week-ends and holidays. However the scope of this conflict went beyond the specific issue upon which it crystallised at the time. The general negotiations about the provider-payer contractual reorganization and the subsequent fee increases of 2002 and 2003 contributed to defusing the situation (see previous reports: Provider-Payer Contractual Reoganization and Reorganization of health insurance governance).

Over this period, the specific issue of after hours care received specific attention and changes took place at the central as well as the local level.

Purpose and process analysis

Current Process Stages

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

Origins of health policy idea

This policy development was driven at the national level by the 2001 strikes and the following response of the government (commissioning of an expert's report in 2002 and consultations followed by a change in legislation in 2003).

It is however interesting to note that this issue being local in essence, many regions tried to find their own solutions and launched specific projects over the period. The institutions involved at the regional level were usually the département level medical association (Conseil de l'Ordre Départemental), the regional associations which represent private practice physicians (URML, Union régionale des médecins libéraux), the Regional Federations of Health Insurance Funds (URCAM, Unions régionales des caisses d'assurance maladie).

A recent article identified 10 models of solutions which emerged, and can be grouped into 3 main types of after hours services organization:

• dedicated facilities, many of which are labelled "on-call houses" (maisons de gardes). These consulting rooms  are usually located near or within local hospitals; They are staffed by a rotating team of local physicians and patients are invited to go there after hours; 
• dedicated physicians. In some areas voluntary physicians take on the bulk of the after hours shifts, covering broad sectors in exchange for a better remuneration;
• call centres. A regulating physician filters the calls and contacts the person on call if necessary.

Stakeholder positions

Following the guidelines set in a much contested wider-scoped agreement signed by health insurance funds and a minority GP union in January 2002, a specific protocol on after hours care was signed on the 1st of March 2002 between the Medical Association's President, the health insurance funds and the government.

According to the protocol, the geographical sectors within which the after hours care had to be organized was going to be redesigned. At the department level (a department is an administrative unit of 600 000 inhabitants on average), the local medical associations would draw lists of physicians who had to participate in a given area and, when needed, would designate the physicians on call. A fixed remuneration of 50€ was planned for each 12 hour shift which would have topped up the physician's fee.

This protocol was widely rejected by physicians unions and members of the medical association whose president was forced to resign. The main point of friction was the shift from a voluntary to a mandatory participation in the system.

In July 2002, the Minister of health commissioned a report to a senator, Charles Descours. His report was published in January 2003 and proposed a new system based on the following principles:

• The participation of physicians remains voluntary, but, as before, last resort solutions can be enforced by the department medical association and ultimately by the local authority;
• the after hours provision of ambulatory care is organized at the department level. Each department is divided in sub-sectors in order to guarantee a fast and adequate response over the territory.
• A medical call centre is organized at the department level to regulate demands after hours. 

These propositions represent a compromise between the initial position of the physicians on the one hand, who wanted a system strictly based on a voluntary basis and the public authorities at large on the other hand whose purpose was to ensure that care would always be available. In essence, now, every one has acknowledged that there is a collective obligation but has agreed that the organization will still primarily rely on a voluntary participation.

Influences in policy making and legislation

The first outcome of this process was a legal definition of the concept of the after hours provision of ambulatory care (permanence des soins): a new article of the public health code now clearly states that private practice physicians have to participate to it in the general interest.

Two decrees were published in September 2003 and they draw heavily on the propositions earlier made by Descours (see above). One decree simply changes the physician's code of deontology to take the new definition into account, while the second one details the new system: the hours covered, the way physicians have to participate, the definition of sub-departmental sectors, the phone regulation. The decree also clarifies the responsibilities in the new system and in particular who is ultimately responsible for drawing the on-call roster.

Adoption and implementation

In many regions, local organizations representing physicians and public authorities have pooled their resources and collaborated to conduct detailed assessments of the current situation. They are also deciding the criteria that should be used to map the sub-department sectors using for instance patient flows.

Yet an optimal organization remains to be found. There are two main obstacles:

1. In some areas where the after-hours provision of care was satisfactorily organized, the new rules set by the decree are in contradiction with the existing local arrangements and even compromise recent experiences that had been set-up by local actors.
2. The issue of remuneration remains to be dealt with. Some solutions were found locally but they may not be sustainable or transferable to other areas. Physician unions are paying a lot of attention to this issue.

The senator Descours was commissioned to monitor the progress of this project and to start negotiations on the issue of remuneration.

Monitoring and evaluation

Some actors have been monitoring the progress of this change but no formal evaluation is planned:

The national medical association conducted a survey to which 97 departments responded: As of January 2004, 80 of them had an updated on-call roster and 65 had redefined the sub-deparment sectors.

The senator Descours recently stated that "50% of departments have a rather efficient system, 30% have uneven results and 20% have not reached a plausible agreement".

Expected outcome

The new system aims at achieve a better local organization of the provision of care and may succeed. A possible positive outcome would be to alleviate the rural physicians workload thereby creating an incentive for young physicians to set up shop in underserved areas. Whether it will be sufficient difficult remains to be seen and this issue is dealt with at a broader level in another policy that aims at attracting physicians in such areas.

Other issues in the public debate such as the new schedule fee (nomenclature), whose implementation should come soon, or even the health insurance reform, if it takes place, could well spark off a new conflict between private practice physicians and public authorities. The issue of after hours care being one that easily prompts sympathy from the public could again be used to express a more general dissatisfaction.

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

This policy aims at improving the provision of care and will therefore have a positive impact on quality and equity. Fee increases were granted after the strikes of 2001 (the flat fee for a duty shift in addition to more general increases for GPs in particular for home visits). Still the funds that go towards remunerating after hours care are deemed insufficient and in order for the system to work the payrs may have to give more. The price of quality may prove high.

References

Sources of Information

Décret N°2003-880 du 15 septembre 2003 relatif aux modalités d'organisation de la permanence des soins (www.legifrance.gouv.fr)

Décret N°2003-881 du 15 septembre 2003 modifiant l'article 77 du décret n°95-1000 du 6 septembre 1995 portant sur le code de déontologie médicale (www.legifrance.gouv.fr)

« La permanence des soins » rapport du groupe de travail présidé par le sénateur Charles Descours, janvier 2003 (www.sante.gouv.frhtmactudescours2)

« Gardes, dix modèles qui marchent », Impact médecine n°67, feb. 13 2004, pp. 36-40.

 « La permanence des soins en Languedoc Roussillon. Etats des lieux, méthodologie et indicateurs régionaux », DRSM, URCAM, ARCMSA and ARH Languedoc Roussillon, nov. 2003.

« Enquête auprès des conseils départementaux de l'Ordre des médecins », jan. 2004 (www.cnom.fr).

Author/s and/or contributors to this survey

Agnès Couffinhal, Véronique Lucas

Suggested citation for this online article

Agnès Couffinhal, Véronique Lucas. "Reorganization of after hours ambulatory care". Health Policy Monitor, April 2004. Available at http://www.hpm.org/survey/fr/a3/4