Regional healthcare 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 major parameters of organisation and planning of healthcare facilities have been modified substantially by redefining the role of regional strategic health plans (SROS - Schéma régional d'organisation sanitaire). The new plans put greater emphasis on the health care needs of the population at the local level and promote an integrated health care approach coordinating prevention, acute and rehabilitation care.

Purpose of health policy or idea

With the ordinance of September 2003, the strategic regional health plans (SROS in French) became the main tool of planning and distributing hospital resources in France. The reform aims to simplify hospital planning by merging several planning tools and to reinforce the role of regional hospital agencies in controlling local hospital activities.

The new SROS (SROS3) have been implemented since the beginning of 2006 and brought some major structural changes in health care planning

• First of all, the sanitary chart, a central planning tool, which used to control, among other things, the number of beds and medical equipment authorised for each hospital has been abolished.
• Second, new "health territories" are defined taking into account better local health needs, essentially defined by mortality and morbidity information, socio-economic characteristics and existing medical resources not only in hospitals but also in the ambulatory sector. These territories provide now the major framework for organising the supply of hospital equipment.
• Third, "medical plans" for each territory are developed identifying local health care objectives and specific health care services to be improved to reach these objectives (This could involve centralisation of some activities such as "maternal care", creation/installation of new services or improving the availability of emergency care in out-of-office hours.). These local health care plans for the territory aim to reconcile availability of services at the local level with specialisation of certain type of care (following a hierarchy) in a coherent plan promoting collaboration between hospitals and health care professionals.
• Forth, individual hospitals have to contract with the regional hospital agencies to describe the level and type of activity that they would be carrying out over the next five years in line with the needs of the local population. Hospitals have to declare and negotiate quantitative objectives for their activity levels (by type).

Overall, the "medical plan" for a health territory structures all individual hospital plans/contracts in that territory. Objectives and resources demanded have to be coherent. 

More generally, this new generation of health plans requires a more integrated approach to health care planning. Regional hospital agencies are not only responsible for organising the acute care supply but also prevention, rehabilitative and long-term care. Coordination between ambulatory services, social services and hospital care is required.

Main points

Main objectives

• Improve territorial organization of health care to better satisfy the local health needs.
• Promote collaboration between hospitals and health professionals working in the ambulatory sector for a more integrated approach to health care provision.

Type of incentives

Regulatory

Groups affected

Ministry of Health, regional hospital agencies (ARHs), hospitals, elected representatives and users of health 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

Hospital planning in France has been very centralised and rigid since 1970. Both public and private hospitals required to have authorisation to increase their bed numbers or to buy heavy medical equipment. The authorisations were regulated by the "medical map" (carte sanitaire), which set out target capacities by geographical area.

Deconcentration of hospital sector planning to better satisfy regional health needs has been part of the major hospital reform plan "Hospital 2007" (HPM survey (9)2007).

Until 2006, hospital planning has been carried out for 5 yearly periods with two legal instruments: hospital map (sanitary chart) and regional strategic health plans (SROS).

• The hospital map was established during the 1970s in order to decide on the type and the volume of heavy medical equipment in each region. Hospital map divided the country into 256 health sectors. National standards, such as bed/population ratios and medical equipment/population ratios, were used to quantify and to arbitrate medical supply between regions.
• SROSs were introduced in 1991 to improve the geographical equity of hospital care provision. Initially these plans aimed to ensure regional equity in access and to control health care expenditures at the regional level. Gradually the plans evolved promoting the preventive and palliative care supply as well as curative care.
• Hospital planning with quotas was abolished in 2003. The SROS became the main instrument of planning and distributing hospital resources since then.

Purpose and process analysis

Current Process Stages

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

Initiators of idea/main actors

• Government

• Providers

• Patients, Consumers

Approach of idea

The approach of the idea is described as:
renewed:

Stakeholder positions

The idea seems to be well-accepted by most stakeholders. The elected representatives and hospital federations recognize that the new "health territory" approach can improve the organization frame, especially by increasing the dialogue between different actors.

Actors and positions

Government
Ministry of Health	very supportive		strongly opposed
Regional hospital agencies	very supportive		strongly opposed
Providers
hospitals	very supportive		strongly opposed
health professionals	very supportive		strongly opposed
Patients, Consumers
patients	very supportive		strongly opposed

Actors and influence

Government
Ministry of Health	very strong		none
Regional hospital agencies	very strong		none
Providers
hospitals	very strong		none
health professionals	very strong		none
Patients, Consumers
patients	very strong		none

Positions and Influences at a glance

Adoption and implementation

The definition of SROS was preceded by a national consultation process on general directions. This preliminary work is organized around a think tank which brought together medical professions, the Ministry of Health, hospital federations, regional hospital agencies, national and regional unions of the insurance funds, local/regional planning department and independent experts.

The Regional Hospital Agencies have the main responsibility for preparing the SROS for the period of 2006-2011. The preparation involved meetings and collaboration between health professionals, hospitals federations, ambulatory actors, elected representatives and users over a period of two years.

At the end of March 2006, the SROSs were adopted. They define for each health territory a medical project which describes precisely the actions to be carried out over the next five years to reach a set of specific local objectives.

Contracts defining specific health service objectives were signed between hospitals and regional hospital agencies in March 2007.

Monitoring and evaluation

The ordinance of September 2003 and the public health law voted on in August 2004 imply that there should be an evaluation of the SROS, but no specific procedure for evaluation is suggested.

Some regions like Rhône-Alpes have already started an evaluation process based on objectives defined in the SROS. For the moment, they are working on data collection for evaluating SROS and the agreements made with hospitals.

Expected outcome

Hospital management becoming more regional (less central) should improve the satisfaction at the local level.

Nevertheless, the hospital payment reform (called T2A) which introduced a new case mix-based prospective payment system (see the HPM report (5)2005) might create conflicting pressures. For example, T2A encourages hospitals to increase their acute care activity while quantitative objectives fixed by the regional hospital agencies (ARHs) try to limit it. Some observers think that the hospital payment reform will have a bigger impact on the restructuring of hospital supply than SROS.

Moreover, while SROS brings a new approach to the regulation of inpatient care facilities, currently there is no real territorial organisation of outpatient care. The freedom of installation is firmly defended by liberal physicians, despite the very unequal territorial distribution of medical care. [The National health Conference demanded recently to restrain extra-billing to patients to improve the equity in access. There are some propositions for restricting physicians' freedom of installation (with negative financial sanctions) in the 2008 project for financing social security, but this received strong opposition from physicians and medical students]. The idea of creating new regional health agencies, with enlarged mission of controlling inpatient care, outpatient care and public health plans, was in the presidential programme of Nicolas Sarkozy. Their possible creation could completely change the healthcare organisation landscape.

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

Establishment of strategic regional plans (SROSs). Ordinance of 4th September 2003, available at www.legifrance.gouv.fr 

Ministry of Health. Territoires et accès aux soins. (Preliminary publication on the definition of health territories). Paris, 2003. Available at www.sante.gouv.fr/htm/publication/dhos/sros/sommaire.htm 

Ministry of Health. Plan Hôpital 2007. www.sante.gouv.fr/htm/dossiers/hopital2007  

Safon, Marie-Odilde. L'hôpital en France: 1995-2005. (Hospital in France: 1995-2005. A bibliography). Documentation de l'IRDES, December 2006. Available at www.irdes.fr/EspaceDoc/DossiersBiblios/HopitalFrance.pdf

Reform formerly reported in

Hospital and medical equipment planning Process Stages: Implementation

Author/s and/or contributors to this survey

Véronique, Lucas-Gabrielli and Coldefy Magali

Suggested citation for this online article

Véronique, Lucas-Gabrielli and Coldefy Magali. "Regional healthcare planning". Health Policy Monitor, October 2007. Available at http://www.hpm.org/survey/fr/a10/4