Regulating nurses - follow up

• Abstract
• Characteristics of this policy
• Purpose and process analysis
• Expected outcome
• References

Featured in half-yearly report: Health Policy Developments 12

Abstract

Following the framework agreement signed in 2007 between the unions of private nurses and the sickness funds, an amendment was passed in September 2008 setting out the conditions for regulating the regional distribution of nurses’ activity. In particular, nurses' freedom of installation will be restricted in areas with high nurse density. In return, financial and material incentives are proposed for encouraging settlement in under-served areas.

Recent developments

In June 2007, a framework agreement was signed between the four private (self-employed) nurse unions and the National Union of Sickness Funds for improving, among other things, the geographic distribution of nurses (see HPM 10/2007, New nursing regulation).

After a year of negotiation, an amendement to this agrement was signed in September 2008 to clarify the conditions for regulating nurse practice over the territory. The agreement was initially made for two years and is considered to be experimental. There are three main points:

1. Nurses obtained a general pay rise (10% increase of their hourly wage over two years). This aims to make nursing more attractive against a possible future nursing shortage.
2. A number of material and financial benefits are offered to nurses who are working or want to install their practice in areas defined as "under-served". The financial advantages offered are quite significant and could represent up to 20% of their yearly gross income.
3. Most importantly, there will be a strict control over nurse settlement in areas where nurse density is already high. It is agreed that, unless there is an exit, no authorisation will be given for installing a practice in these areas.  

The mission of defining (based on national criteria) and controlling "under-served" and "over-served" areas is given to the Regional Health Missions (Mission régional de santé) which consist of representatives of sickness funds and state authorities, but in the long term this role will be given to the future Regional Health Agencies (see HPM, 2008/12, New regional health governance").

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
current    previous

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

• Payers

Stakeholder positions

The initiator of this amendment is the government who aims to send a strong message with this agreement to all other health care professionals, in particular to physicians. The freedom of installation has always been a non-negotiable principle for physicians. The government wants to show that it is possible to regulate and put limits to this freedom to improve regional distribution.

The national union of sickness funds is the main negociator and pushed hard for obtaining concreate measures for regulating nurses settlement against increasing their fees.

The private nurse unions first refused to sign the agreement, as part-time private nurses providing home care services were not included in the agreement. There are many private nurses who are employed by nursing homes on a part-time salary basis and have their own practice in parallel. Not regulating their practice would create unequal competition. 

A report prepared by the General Audit Commission (IGAS) for the Ministry of Health in 2008 succeeded in deblocking the situation by convincing the government and the sickness funds to include nursing home services in the geographical regulation scheme. 

Physician unions are strongly against this agreement. They see this agreement as an indicator of the intention of the government to challenge their freedom of installation as a next step. So far, the government has tried to reduce existing geographical variations in the distribution of physicians mainly be offering them incentives (see HPM 7/2006 Demographic plan for health professionals).

Actors and positions

Government
Ministry of Health	very supportive		strongly opposed
Providers
Private nurse unions	very supportive		strongly opposed
Physician unions	very supportive		strongly opposed
Payers
National union of sickness fund	very supportive		strongly opposed
current    previous

Actors and influence

Government
Ministry of Health	very strong		none
Providers
Private nurse unions	very strong		none
Physician unions	very strong		none
Payers
National union of sickness fund	very strong		none
current    previous

Positions and Influences at a glance

Adoption and implementation

The agreement is for the next two years (starting in 2009)  and considered to be experimental. In order for the agreement to become operational, first the  the Regional Health Missions have to define which are the over/under-served areas according to national criterions (There is no fixed date for when these definitions are to be provided).

What the critera for defining under/over-served areas will be is not yet clear.

In the long run, the future Regional Health Agencies will take over the responsibility for regulating the regional nurse supply. The law defining new regional governance rules (HPM 2008/12) which will be voted on in parliament in January 2009 will be a determinant for the continuity of this policy.

Monitoring and evaluation

Evaluation of this experimental phase is supposed to be carried out by a specific national observatory. However, for the moment nobody knows who will be in this observatory and how the evaluation will be carried out.

Expected outcome

At the moment, it is difficult to predict how effective these measures will be in influencing nurses' settlement decisions since the high/low density areas are not yet defined. One risk could be that given the impossibility to work in attractive (potentially over-served) areas, they choose not to practice at all. The financial incentives provided for settling in low-density areas are quite significant, but clearly there are other factors influencing the decision of installing in an area.

Overall, this agreement has the potential to improve the access to nursing care by reducing regional disparities in nurse availability. But beyond this, it has symbolic importance for the government as a signal of its intention to regulate physicians' settlement practices.

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
current    previous

References

Sources of Information

Ministry of Health. Arrêté du 18 juillet 2007 portant approbation de la convention nationale destinée à régir les rapports entre les infirmières et les infirmiers libéraux et les organismes d'assurance maladie. July 2007. www.legifrance.gouv.fr/imagesJOE/2007/0725/joe_20070725_0170_0033.pdf

Ministry of Health. Arrêté du 17 octobre 2008 portant approbation de l'avenant n° 1 à la convention nationale des infirmières et infirmiers libéraux, JO du 18/10/08. http://www.legifrance.gouv.fr/

Ministry of Health audit commission ( IGAS). Note de synthèse du groupe de travail - février 2008 http://lesrapports.ladocumentationfrancaise.fr/BRP/084000329/0000.pdf

Reform formerly reported in

New nursing regulation Process Stages: Legislation

Author/s and/or contributors to this survey

Musques, Julien and Michel Naidich

Suggested citation for this online article

Musques, Julien and Michel Naidich. "Regulating nurses - follow up". Health Policy Monitor, October 2008. Available at http://www.hpm.org/survey/fr/a12/1