Quelles solutions pour la garde en médecine générale? - KCE

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120 8.4.4. After-hhours care in Frrance Items Expert(s) interviewwed Emgan QUERRELLOU Isabelle Aubin-Auger (Secrétaire générale CNGE; i.aubin@cnge.fr) Literature base National and international publications on the topic of aftter-hours care in Francce Characteristics off the Population off 63.8 million in metrop politan France health system with France has a social insurance syst tem financed by emplooyer–employee payrolll taxes and central taxxes. relevance to after- 2007: total exxpenditure on health in n France was estimateed at €208 billion or 111% of gross domestic product (GDP), of whhich 79% is publicly funnded. hours services Expenditure oon personal health care accounted for 88% of total expenditure oon health and represennts an average of €28995 per person. Statutory insuurance covers all resid dents for hospital and ambulatory care, presscription drugs, and, too a lesser extent, denttal and optometry caree. Cost-sharing requirements apply to o all publicly covered sservices, although these are waived for patients with any of 30 chhronic diseases. Roughly ninee of 10 residents have complementary privaate insurance that coveers most cost-sharing charges under the puublic system; they eithher obtain this insurancee themselves (usually through employment) ) or, if they have low inncome, have it provideed by the government. Since 2000: in order to ensure tha at measures increasinng patients’ co-insurannce would not increasse social inequities in access, public compleementary insurance (coomplementary univers sal health coverage ( (couverture maladie uuniverselle complémeentaire, CMU-C)) is offfered on a voluntaryy basis to lower socioecconomic groups. It cov vers 7% of the population. Ambulatory ccare is provided mostly by self-employed pphysicians paid fee-forr-service. Tariffs are nnegotiated in pluri-annnual agreements betwween SHI and represenntatives of health profe essionals. Since 2004: rregistration with prima ary care physicians whho act as gatekeeperss has been encourageed through higher coppayments for self-referrrals, and roughly 90 peercent of the populatio on is now registered. A further primmary care reform has been the 2009 introduuction of pay-for-perfoormance, with GPs abble to earn up to €5,0000 for achieving qualitty targets on preventionn, chronic disease management, and drug pprescriptions. Responsibilityy for capacity planning is shared by the central and the regional level. At the regionall level, the ARSs weree implemented in Apriil 2010 to coordinate ambulatory and hospit tal care and health aand social care for the elderly and disabbled through a regionnal strategic health plan (plan stratégique réégional de santé; PRS S) that is based on population needs. Each sector’s planning proccess will have to comply with the PRS. Thiss is a first attempt at reggional planning of the ambulatory care sectoor. Quality of carre is regulated at the national n level. 122 500 self--employed GPs (2009) Most French patients have chosen a preferred doctor (855% in 2008) which is aalmost always a GP (mmore than 99%). 40% of self-eemployed physicians are a involved in group practices. Physicianss involved in group praactice never share a common patient list bbut aim to ensure continnuity of care (through shared s electronic recoords) and mutualize exxtensive capital investtments. Situation before After-hours care was historically or rganized by the local ccentre of the Physicianns Association, which scheduled on-call rouunds. reform Drivers for systemm - Self-employyed GPs, whose numb ber is scarce in certainn areas and whose woorkload was increasingg, became increasinglly reluctant to participaate in the reform on after-hoours rota system. care - Hospital emmergency departments s dealt with an increaasing workload. The ooverload of these deppartments has been reelated to the lack of aaccess to primary care ambulatory services as a well as to a lack of available hospital bedds for emergency admissions. System reform sinnce and type of reformm Affter-Hours Primaary Care Resullts Remark: Theere is widespread conc cern in France about tthe excessive use of tthe SAMU in circumsttances that prove not tto be warranted. In thheory, if a patient calls oout the SAMU and it proves p not to be a real emergency, the doctoor or hospital receivingg the patient may be uunwilling to sign off a ttreatment certificate, ass a result of which the patient will be expecteed to pay the costs. Between 20003 and 2005: Developmentt of ambulatory care centres (les maisonss médicales de garde; MMG) that are acccessible during nightts and weekends, in order to guarantee coontinuity of access to care. c This attempt hass been only partly succcessful, mainly becauuse of difficulties in hiring physicians for nigght shifts. KCE Reportss 171
KCE Reports 1771 Items Number of actual models used: Type of models Affter-Hours Primaary Care Resullts The system is still facing difficulties s in several regions, mmainly through the reluuctance of physicians to participate in underr-served areas. As a rresponse, the 2009 HPSST Act developed mea asures to improve PDS, which now falls undder the responsibility oof ARSs. The new systtem (development of ambulatory a care centrres) falls under the ressponsibility of the repreesentative of the statee in each department ( (préfet de département) ), who is in charge of o organizing it with thhe help of the local CCommittee for Emergeency Care, Continuityy of Care and Transpportations (comité dépaartemental de l’aide mé édicale urgente, de la permanence des soinns et des transports saanitaires; CODAMUPSS). Since 2005: After-hours ccare has been made voluntary with the CConseil Départementaal de l’Ordre des Méddecins (CDOM) organnising the rotas. Howwever, the regional préfeet may occasionally re equire doctors to makee up for shortfalls in thhe rota system. The level at wwhich after-hours care e is regulated is the “DDépartement”, via a deepartmental board of tthe medical council, broken down into sectoors. After- hours servicee provision is thus a matter for regional auuthorities comprising iindependent bodies oof general practitioners established on a reegional or sometimes loocal level, as specifie ed in the national reguulations. The areas aand rotas are determined by the professionnal doctors’ bodies, wwhich are required to ennsure permanent acce ess to primary care duuring and out of normaal practice hours. The on- call pperiods are relatively short because of the longer regular workingg week (self-employedd doctors being free to fix the opening timees of their practices), whhile these services ma ay be provided indiscriiminately by general ppractitioners or speciallists. Since 2009: The 2009 HPPST Act attempted to o tackle increasing geographical disparities of the health care wworkforce: the responssibility for providing coontinuous access to heaalth care services now w falls under the ARSss, which can contract with ambulatory care physicians in order too meet these goals. In addition, call centres ddedicated to primary care issues have been created in order to reeduce the burden of caalls received by the SAAMU (services d’aide médicale urgente) call centres. There is no ssingle system of after-h hours services, with add hoc regional variatioons taking account of llocal needs and geogrraphical factors. Rota-system (= the conventional on-call o system): rotas being determined by a zoning system conccerning all GPs. Doctoors work voluntarily onn the duty rotas – someetimes exclusively so – and constitute sepparate structures to wwhich part of the AH sservice is subcontraccted. These structuress may be private (e.g. SSOS Médecins in Fran nce). On-call medical centres (=Ambula atory care centres; ‘lees maisons médicaless de garde’) ensuringg continuity of care (ppermanence des soinns; PDS). Services are provided in walk-in centres c by self-employyed doctors working ttheir obligatory on-call hours, or by hospitaal doctors on a flat raate, or by doctors employed exclusively at these centres. Hospital A&EE departments (with direct access). Medical emergency call centres (s services d’aide médicaale urgente; SAMU). The SAMU is a publicc service attached to a hospital and responsible for emergencies in its area. The SAMU: ccan send out a vehicle e that resembles a suurgery on wheels and is accompanied by ann emergency medical team. SAMU call cenntres deal with patient reequests and direct the em depending on the ddemand to on-call phyysicians, hospital emeergency departments oor a doctor’s appointmment. So a single numbeer designed to coordinate emergencies haas been set up, wheree a telephone operatoor (generally a doctorr) determines the typee of care needed and ttransfers the call to th he appropriate centre for treatment. These call centres have beeen created to ensure that primary care andd hospital services operate as one. Since 19 986, SAMU have been freely accessible naationwide from any phhone (by dialing 15). The centres share infformation with the policce (dial 17) and fire brigade b (dial 18) emerrgency call centres, so that medical emerggencies are appropriattely addressed. The EEuropean emergency number “112” is answe ered either by the meddical or the fire brigadee call centres, depending on the departmentt. The system relies on doctors who are on-ccall on a voluntary basis, towards whom finaancial incentives are diirected. There are neaarly 100 SAMU call centres in France each oon run by the local majjor hospital. Many of those manning the ccentres will themselvees be doctors, or at tthe least, trained meddical staff.  Dependinng on the circumstancees, they are able to org ganise transport to hosspital, a home visit by a doctor or simply meedical advice over the telephone.  Since 2003: the principle of prior r screening of requessts for non-elective caare has been adopteed, implying in principple a protocol classifyying calls 121
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KCE REPORTS 2011 171B QUELLLES SOOL
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Contrôle Direction Contact Comm mi
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COLOPHOON Titre : Auteurs : Experts
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KCE Reports 1771B PRÉFFACE Il y a
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KCE Reports 1771B Obstacles liéés
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KCE Reports 1771B Autres alternnati
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KCE Reports 1771B Garddes en médec
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KCE Reports 1771B SYNTTHÈSE Garde
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KCE Reports 1771B 1.3.2. Chargees d
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KCE Reports 1771B La plupart des é
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KCE Reports 1771B n'est pas le cass
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KCE Reports 1771B PROCESSUS PROCÉD
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KCE Reports 1771 SCIENTIFIC RREPOR
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KCE Reports 171 Affter-Hours Primaa
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KCE Reports 171 Affter-Hours Primaa
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KCE Reports 1771 LIST OF FFIGURES L
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KCE Reports 1771 LIST OF AABBREVIAT
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KCE Reports 1771 Affter-Hours Prima
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KCE Reports 1771 1.1.3. Initial The
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KCE Reports 1771 below. 15 The eeva
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KCE Reports 1771 2.6. Uniquee call
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KCE Reports 1771 • Advising thhe
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KCE Reports 1771 regarding tthe org
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KCE Reports 1771 • The GP By join
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KCE Reports 1771 sanctioning coompe
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KCE Reports 1771 contacts and too s
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KCE Reports 1771 Table 3: Numbber o
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KCE Reports 1771 4.2.2.3. Limmitati
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KCE Reports 1771 When looking at ag
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KCE Reports 1771 4.3.2. Type of are
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KCE Reports 1771 1.a.Use oof search
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KCE Reports 1771 • perceived work
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KCE Reports 1771 Continuity of c as
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KCE Reports 1771 • The safetyy of
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KCE Reports 1771 5.4.4. Financial i
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KCE Reports 1771 the ambulance serv
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KCE Reports 1771 5.4.9.1. Thee Neth
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KCE Reports 1771 the patient’s ne
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KCE Reports 1771 • To assesss the
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KCE Reports 1771 6.1.1.1. Thee Neth
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KCE Reports 1771 between € 14 inn
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KCE Reports 1771 Table 16 : Disstri
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KCE Reports 1771 The NIHDI tablees
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KCE Reports 1771 Some demograaphic
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KCE Reports 1771 In the same wway,
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KCE Reports 1771 8. APPEENDICES 8.1
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Page 103 and 104: KCE Reports 1771 Place, Populattion
Page 105 and 106: KCE Reports 1771 • Eviter les pat
Page 107 and 108: KCE Reports 1771 Nombre de vissites
Page 109 and 110: KCE Reports 1771 • Prévoir dees
Page 111 and 112: KCE Reports 1771 appelss, délais e
Page 113 and 114: KCE Reports 1771 8.3.4.4. Othhers T
Page 115 and 116: KCE Reports 1771 • One difficuult
Page 117 and 118: KCE Reports 1771 personnes (réggio
Page 119 and 120: KCE Reports 1771 • Réponse à un
Page 121 and 122: KCE Reports 1771 overchargee of som
Page 123 and 124: KCE Reports 1771 Items System refor
Page 125 and 126: KCE Reports 1771 Items Who does the
Page 127 and 128: KCE Reports 1771 8.4.1.1. Weebsites
Page 129 and 130: KCE Reports 1771 study of twwo inte
Page 131 and 132: KCE Reports 1771 Items Main drivers
Page 133 and 134: KCE Reports 1771 Items Affter-Hours
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Page 137 and 138: KCE Reports 1771 Items Suggestions
Page 139 and 140: KCE Reports 1771 10. Dale J, Croouc
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Page 155 and 156: KCE Reports 1771 INAMI/RIZIV/NIHDI
Page 157 and 158: KCE Reports 1771 o Avec l Il y a de
Page 159 and 160: KCE Reports 1771 compléter les sse
Page 161 and 162: KCE Reports 1771 des accords de soi
Page 163 and 164: KCE Reports 1771 qui seerait de gar
Page 165 and 166: KCE Reports 1771 8.5.2.2. Norrmes e
Page 167 and 168: KCE Reports 1771 • Les norme Deux
Page 169 and 170: KCE Reports 1771 S’il ne particip
Page 171 and 172: KCE Reports 1771 Des deux dispoosit
Page 173 and 174: KCE Reports 1771 L’article 9, §
Page 175 and 176: KCE Reports 1771 o En ou grave. A c
Page 177 and 178: KCE Reports 1771 L’on envisage s
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Page 181 and 182: KCE Reports 1771 Affter-Hours Prima
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Page 185 and 186: KCE Reports 1771 o De aaangestelde
Page 187 and 188: KCE Reports 1771 De standaardlijs b
Page 189 and 190: KCE Reports 1771 de 1733-centrrales
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KCE Reports 1771 De arts die dooor
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KCE Reports 1771 rétablissemment d
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KCE Reports 1771 peuplée et une zo
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KCE Reports 1771 Code de nomenclatu
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KCE Reports 1771 8.6.3.2. Nummber o
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KCE Reports 1771 Number of outt-of-
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KCE Reports 1771 8.7. Appenddices:
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KCE Reports 1771 8.7.2.2. Thirrd ye
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KCE Reports 1771 9. REFEERENCES 1.
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KCE Reports 1771 38. Pickin DMM, O'
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KCE Reports 1771 79. Thompsoon F, G
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KCE Reports 1771 121. Arrêté roya
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KCE Reports 1771 Tijdschrifft van d
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