By Fabien Cramard, Manager
In a context where medical demographics are very fragile and even precarious, public health establishments are facing a real headache. How can we ensure a continuity of care that meets the needs of the population while optimizing medical time and better meeting the requirements of quality of life in the workplace for caregivers? This is the dilemma addressed by the recently proposed law «Improving access to care through the territorial commitment of professionals».», promulgated on December 27, is an attempt to respond. The aim is to give regional health agencies greater flexibility to organize local health structures and rebalance the medical forces present. To succeed in this major restructuring, however, they need to take into account a number of unavoidable imperatives. An overview the challenges and conditions for success of this necessary transformation of our healthcare system.
Permanence of care: an essential public service mission to meet local needs
Permanence des soins (PDS) is a public service mission, designed to meet the need for unscheduled health care outside normal opening hours. It differs from continuity of care, which is a regulatory obligation for all care units to ensure the care of patients already hospitalized (over the same periods). Continuity of care is organized and divided between the public and private sectors:
- In the private sector, through the organization of permanent outpatient care (PDSA)
- In emergency departments (EDs)
- In healthcare establishments, through the permanent care service (PDSES)
To strengthen the balance and overall efficiency of the healthcare system, a host of initiatives have emerged alongside the SDP, including Service d'Accès aux Soins (SAS), recently rolled out nationwide. The aim of this new service is to guide people through their healthcare pathway and enable them to access a healthcare professional at any time, whether in the public or private sector.
Local organization struggles to find the right scale
To manage the care that falls within its scope, the PDSES must mobilize healthcare resources and technical platforms on a regional scale. Local coverage is necessary to meet the need for local service and limit lost opportunities. As a result, a large number of hospitals with emergency services and technical platforms now have an extensive PDSES in a large number of specialties, sometimes in the same region.
However, given the constraints imposed by the population's growing need for medical care and the shortage of medical resources, the organization of the PDSES needs to evolve to reach its full potential.
There are many reasons for poor performance
The PDSES, evolving in a «disparate» and fragile environment
- Growing demographic pressure
- Unpleasant working conditions with repeated on-call duty and on-call duty in the face of a hospital medical demography under pressure
- Healthcare professionals' higher expectations in terms of quality of life at work
- Fragile healthcare organizations
- Heterogeneity of regional PDSES deployment methods
- Imbalance in contributions between public and private sectors
The imbalance between public and private is widening
In 2023, the Minister of Health and Prevention referred to the’inspection générale des affaires sociales (IGAS) to carry out a mission on the functioning of the PDSES and the challenges to be met in order to maintain this system over the long term. The surveys carried out as part of this mission highlight the role of public establishments, which provide 82% of on-call duty and 77% of on-call duty.
In fact, the PDSES is the «dead weight» of public teams. They have to cope with this burden, which has a significant impact on their quality of working life. It takes 5 full-time doctors to ensure a sustainable level of on-call care for the teams. On average, however, the medical teams at small and medium-sized general hospitals are made up of 2 to 3 practitioners per specialty discipline.
Existing organizations, which rely on a limited number of practitioners, maintain the PDSES's dependence on external resources and additional financial rewards, at a time when the budgetary and financial context is particularly tense.
An in-depth overhaul of this flagship scheme is urgently needed
In light of these findings, on December 18 the Senate passed a bill aimed at Improving access to care through the territorial commitment of professionals.
- A new regional PDSES organization scheme for greater consistency and fairness
Given the difficulties experienced in recent years, ARS must take full ownership of the issue, and redesign the regional scheme for organizing and operating the PDSES.. It will be based on 3 structuring pillars:
- A better taking into account the needs of each region
- A better assessment of the medical forces involved
- All healthcare professionals need to understand that a « collective responsibility "
So, by distributing the effort between all the structures and doctors in a given region, the government's ambition is above all to restore a better organizational, medical and financial balance between public and private establishments.
The aim is also to standardize the way PDSES is implemented in the regions, while preserving a degree of flexibility to take account of certain local specificities.
However, the restructuring of such a system to improve our healthcare system can only succeed if several key guidelines are observed. There are five of them:
- First of all, share on-call and on-call duty lines between a number of public or private structures in a given region, in order to strengthen solidarity in situations of medical shortage
- Provide a response and organization adapted to the needs expressed within each structure
- Efforts will need to be focused on pooling certain skills and profiles to serve the PDSES, regardless of the structure to which the healthcare professional is attached.
- The new regional plan should ensure a better match between the financial dimension and the reality of the missions performed: stability and equity between on-call and on-call duty, system sustainability, etc.
- Last but not least, the success of this overhaul will not be possible without taking into account the human side of the operation. It will therefore be necessary to find ways of better recognizing and supporting practitioners who work at night, as well as on weekends and public holidays.
It remains to be seen whether such ambitions will be operational in a context marked by severe pressure on medical demographics.
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