Demographic plan for health professionals

• 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: Health Policy Developments 7/8

Abstract

In order to improve the access to health care and reduce existing geographical variations in the distribution of health professionals a national demographic plan was introduced in January 2006. The plan develops incentives for doctors to practice in medically deprived areas, proposes measures for improving doctors? working conditions and increasing the number of practicing doctors.

Purpose of health policy or idea

In France, the number of doctors is currently quite high compared with other countries (in all 203 000 of which 103 000 specialists and 100 000 GPs; France had 3.4 practising physicians per 1000 population in 2004, above the OECD average of 3). However, the geographical distribution of doctors between regions is quite uneven (more than twofold difference between north and south) and the expected wave of retirement of doctors' in the near future will make this situation worse. The current government announced a new strategic plan in January 2006 for improving health workforce development. The plan develops measures along three axes:  

1. Improving the supply of doctors in medically deprived areas

Deprived areas are defined by two criteria: medical density (areas where the number of doctors is 30% below national average) and professional activity (areas where per capita medical activity in terms of patient visits, etc. is 30% above the national average). The precise list of areas is set by regional authorities after consultation with regional stakeholders.

Doctors working in medically deprived areas are facing unattractive working conditions, including long working hours and lack of time for continuing medical education. This situation discourages young doctors from setting up practices in such areas. The plan provides several incentives in order to encourage group practice and to improve working conditions in these areas:

• The health insurance fund will pay a 20% higher remuneration to doctors working in a group practice in medically deprived areas.
• Local authorities in rural areas will be able to provide financial aid to doctors who wish to set up a practice (for a minimum period of three years) in deficit areas, or provide them with professional building amenities or personal housing. They can also give a study allowance up to 24 000 euros, offer a housing grant up to 400 euros per month or provide accommodation to medical students in their sixth years of study and over if they guarantee that they will settle down for a minimum period of 5 years in a medically deprived area.
• Doctors participating in out-of-hour service in such areas benefit from a tax revenue rebate on their income from this activity (up to a maximum of 60 days or 9000 euros per year).

A single regional office will be in charge of diffusing all available information on these incentives in order to increase doctors' knowledge and understanding on these incentives.

 2. Improving doctors' working conditions

• It is generally accepted that working in group and in multidisciplinary practices would improve both the quality of care and the quality of life for doctors. The special fund (FAQSV- fond d'aide à la qualité des soins de ville) set up within the national health insurance budget to finance, inter alia, innovations in ambulatory care organisations will be used to make capital investment for setting up multi-speciality group practices.
• A new status "associated partner" is created for young doctors to allow them to join a practice without investing in capital.
• The plan aims to improve the cooperation between doctors and paramedics. Pilot projects that have been carried out since 2005 will be extended and their number will raise from 5 to 14. These pilot projects define a number of very precise medical situations where specific tasks are distributed to other health professionals in practices. For example, management of dialysis is delegated to nurses, prescription of eye glasses to orthoptists. Results of those pilot projects are not yet available, though, and the development of advanced practice nurses patterns is a controversial issue.
• The plan abolished the difference in the maternity leave period for female doctors, which was previously shorter than for the rest of employed women, in order to facilitate conciliation of family and professional life and given the increasing number of female doctors.

3. Increasing the number of doctors and increasing the share of GPs

• The plan increased the numerus clausus which sets the number of entrance to medical schools from 4700 students in 2002, to 6300 in 2005, and to 7000 per year for the period 2006 to 2010.
• From 2006 on, a two-month training in a general practice is offered to medical students in or over their third year of study to improve their knowledge about general practice. Currently, French medical students do not have any training period in general practice before choosing their speciality.
• The share of students entering medical school as well as the number of junior doctors will be increased in the medically deprived areas.
• The plan also introduces measures to encourage doctors to practice for more years and to stop early retirement. The 2003 law reforming retirement rules allows one to have an activity based income on top of her/his pension. The cap on the additional income raises from 30 000 Euros to 40 000 for doctors retiring beyond age 65. Moreover, doctors older than 60 are exempt from out-of-hour shifts.

Main points

Main objectives

Main objectives:

The plan has three major objectives: 1) meeting the target of equal access to health care services, 2) improving the supply of health care professionals trained according to health care needs, and 3) improving doctors' training and their competencies.

Type of incentives

Doctors will receive financial incentives (increase in direct income, tax returns and allowances) if they settle down in a medically underserved area. However, non-financial incentives improving their working conditions are also used.    

Groups affected

Medical doctors

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

This policy provides measures mainly to satisfy local expectations which are largely relayed by the media. Political constraints (influence of doctor's unions in policy decisions) lead to a very limited, marginal and conservative type of measures. The fact that measures are focused on specific "deprived areas" defined by low medical density and high medical activity, limits the impact of these measures, since very few areas are concerned (the areas concerned represent about 2.6 million inhabitants or 4% of the total population and 1600 GPs, 3% of all GPs).

Furthermore, this policy is mainly focused on medical doctors without looking at the situation of other primary health care professionals.

The efficiency of financial incentives which are the main type of measures in this plan are questioned by analysis produced by different reports. 

Therefore, this demographic plan appears to be a short-term and limited impact policy concerning the issues in primary care which require structural changes in both medical education and the organisation of care.

Political and economic background

The introduction of the 35-hour-working week, the UE legislation on working time in hospitals, an increasing share of female doctors (60% of students entering medical studies in 2002), and the change in the young professionals' attitude towards professional involvement lead to a reduction in doctors' working time.  

This situation leads to a relative shortage of doctors in particular in rural and economically deprived areas.

In France, the main tool of medical supply regulation is numerus clausus which limits the number of students entering medical studies and has been reduced steadily from 1971 until 1998. The recent increase in the numerus clausus has not compensated the shortage of doctors yet because of the long length of medical studies.

Moreover, general practice is not attractive to medical students. Students have very little information when they have to choose a specialty. They only get practical experience in hospitals during their education and they do not learn any primary care patterns. General practice is considered an exhausting practice, with high demand from patients. Settlement possibilities are limited in urban areas and the investment required is considered quite high in a fee-for-service payment system. Medical students therefore develop strategies to escape from a general practice career. Indeed in 2005, 600 training posts in general practice remained vacant. Students who were not ranked to access a speciality training position preferred to try again a better position in the 2006 rather than entering general practice training.

That is why there are large  geographical inequalities in primary care across French regions with some of the northern regions having a per capita rate equal to 60 % of the southern regions. 

Complies with

Purpose and process analysis

Current Process Stages

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

Origins of health policy idea

Since a few years, at the regional level, there is growing concern about the reduction in the number of general practitioners density in rural areas. Local representatives are threatened by the expansion of  "medical deserts".  

As a response, in 2005, the Ministry has set up a special commission called the medical demographic commission. This last suggested a large number of measures to reduce regional inequalities in health manpower. The demographic plan takes up most of these recommendations and does not propose any radical changes.

Initiators of idea/main actors

• Government: doctors position ranged from supportive to strongly opposed depending on the meseare under consideration

Approach of idea

The approach of the idea is described as:
renewed:

Stakeholder positions

Two main measures summarize the consensus reached by the commission. These are the respect of free settlement for doctors in ambulatory sector, and the 20% increase in the payment of doctors who practice in deprived areas.

• The first measure reflects the position of medical students associations that refuse any limitation in settlement decisions. Some of the other medical trade-unions dominant at the regional and national level ask for limitations of settlement for young doctors in areas where supply is high.
• The second measure reflects the position of mostly specialist trade-unions who refuse any idea of incitation to group or team practice in which doctors could be paid in other ways than fee-for-services. On the other hand, trade-unions representing GPs criticize the focus on financial incentives in deprived areas, only based on fee for services rather than increase in wages, or other non-financial incentives. More generally, GP organisations ask for a greater recognition of general practice as a whole in research (funding of research positions), in teaching (full time professor in medical school which does not exist at the moment) and in practice (same consultation fee for GPs and specialists). A third party stakeholder are university professors who are mainly specialists and are at the head of medical schools. They are opposed to any development of general practice at university.

Actors and positions

Government
government	very supportive		strongly opposed
providers	very supportive		strongly opposed
local authorities	very supportive		strongly opposed

Influences in policy making and legislation

The demographic plan is mainly driven by the Ministry of Health. All measures rely on ministerial acts such as decree in application of different laws or contract negotiation between the national insurance fund and professional trade-unions. For instance, law on retirement which offers the possibility to cumulate activity and pensions for doctors over 65, law about development of rural territories which anticipate fiscal advantages for doctors who assume permanency or offers possibility for local rural communities to finance internship. Contractual negotiations between medical trade unions and the national insurance fund define conditions of 20% of increase in payments for those doctors who practice in group in underserved areas.

Legislative outcome

n/a

Actors and influence

Government
government	very strong		none
providers	very strong		none
local authorities	very strong		none

Positions and Influences at a glance

Monitoring and evaluation

An evaluation of the plan is not formally planed. However, the follow up of the impact of the plan on the number of doctors and their geographical repartition will be made by the ONDPS (National observatory of health care professionals' demography see survey (6)2005).  

Expected outcome

The plan is expected to reduce the forthcoming relative shortage of  physicians and to improve geographical equity in access to primary care doctors.

The overall cost of setting up the plan is estimated at around 30 to 35 million Euros per year.

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

www.sante.gouv.fr/htm/actu/berland_demomed/sommaire.htm www.sante.gouv.fr/htm/dossiers/demographie_medicale/sommaire.htm

Reform formerly reported in

Provider-Payer Contractual Reorganization Process Stages: Pilot

Author/s and/or contributors to this survey

Yann Bourgueil, Karine Chevreul

Suggested citation for this online article

Yann Bourgueil, Karine Chevreul. "Demographic plan for health professionals". Health Policy Monitor, 14/04/2006. Available at http://www.hpm.org/survey/fr/a7/1