When she saw The divide, the film by Catherine Corsini which recounts a night in the emergency room in a Parisian hospital, Alice, a nurse in a CHU in Auvergne-Rhône-Alpes, cried. “This film shows a reality shared in all departments: task interruptions, the need to juggle between patients, and oversights, because we are constantly interrupted. We become abusive in spite of ourselves. » With ten years of seniority and working two weekends and seven nights a month, she receives 2,130 euros net, bonuses included. She is currently at a standstill, awaiting another job following an attack by a patient suffering from mental disorders. Alice is not the only one to ask questions about the meaning of her job, as evidenced by the multiple departures from the public hospital.
This disaffection of caregivers, in the midst of the fifth wave of Covid-19, is the symptom of a double disease which undermines the public hospital, according to André Grimaldi, professor emeritus of diabetology and co-founder of the Inter-hospital collective: the hospital-company , which gradually brought entrepreneurial management logics into public hospitals, and the absence of a public health service in the city. The challenge is to maintain a real public hospital service, which treats everyone according to their needs, at the lowest cost for the community.
It was in the 1970s that a managerial logic imposed itself on the public hospital in a context of rising health expenditure and slowing economic growth. Over the following decades, several tools were adopted and fully used after the 2008 crisis. Three levers were combined: the hospital budget voted each year in Parliament since 1997 (the Ondam hospital, national objective for health insurance expenditure); activity-based pricing (T2A), a system for distributing this budget between hospitals introduced in 2004 and then extended; and a variable, the “floating point” of the tariffs associated with each act, which determines the level of reimbursement of the hospital by Social Security. The cost of an act is expressed in points and the national value of the point is obtained at the end of the year by dividing the hospital Ondam by the number of points linked to the activity of all the establishments in the country.
To control expenditure, governments therefore do not act on the volume of care, which is a good thing, but adjust prices downwards when activity increases. As a result, hospital directors, who anticipate that the point may drop, encourage their staff to do as many acts as possible to generate the maximum number of points. “The virtuous hospital, which only does what is necessary, is punished by the overactivity of others which lowers the value of the point. It can be in deficit, even when it is at its maximum efficiency. The system is completely rogue”, analyzes economist Brigitte Dormont .
Faced with this, the hospital staff had only two solutions, explains André Grimaldi: either sort the patients and the procedures to keep only the most profitable (this is possible in a private clinic, not in a public hospital which has the legal obligation to welcome everyone); or code activities that are less remunerated by Social Security into activities that are less so… avoiding being caught by the inspection services. “I, like everyone else, practiced overcoding, testifies André Grimaldi in his last book, by multiplying day hospitalizations which are costly for Social Security, but profitable for the hospital. We had been congratulated and given as an example by the director. »
Just in time
The infernal couple Ondam-T2A has another effect: that of leading to a deterioration of care by deteriorating working conditions. As Pierre-Louis Bras, former director of Social Security, reminds us, the volume of care delivered in public hospitals between 2009 and 2019 increased by 19%. Hospital expenditure increased by 24% in value. This was only possible because the change in the price per unit of care was very low, less than 5%, while at the same time very expensive new cancer drugs were arriving.
To achieve this, it is the personnel who have been called upon both in volume (staff) and in value (salary). While the volume of care has increased by 19% in ten years, the number of non-medical staff, including nurses, has grown by only 2.4% (12.4% for medical staff). “The 2010 decade was marked by a very strong increase in labor productivity”, writes Pierre-Louis Bras. A nurse in a neurology follow-up care service, Alice makes the same observation. “The service opened twelve years ago. The staff did not change. » But the patient base has evolved. “Before, those over 70 were not saved. Today, we have more dependent patients who live with multiple pathologies. »
On the pay side, “the average net salary per full-time equivalent in the public hospital in 2018 was -1% compared to the level reached in 2009”, calculated Pierre-Louis Bras. This, while on average private salaries increased by 3.4% and the number of doctors, better paid, grew more over the period.
But the investment rate (buildings, medical devices, etc.), i.e. the share of revenue invested, has also fallen: from 11% in 2010-2011, it was only 5% in 2018. , too little to ensure good maintenance. In addition, from 2017, the volume of care delivered in public hospitals began to slow down, while it is accelerating in private clinics. Could this be the beginning of a rationing of care? This already seems to be at work in view of the drop in the number of beds in full hospitalization: 75,000 beds in medicine, surgery and obstetrics were eliminated between 2003 and 2019 in the name of the “ambulatory shift”. Admittedly, the reduction in the average length of stay is a long-term trend: from seventeen days in 1965, stays were on average less than six days in the mid-1990s. However, the ambulatory, which consists of staying less than a day in the hospital, is suitable for certain activities, such as cataract surgery, but not for others, such as a thyroid operation. The statistical services of the Ministry of Health also consider that a ceiling in terms of outpatient care was reached in 2016 and that it will be difficult to go further. Outpatient care also requires very good care in the city, the involvement of caregivers and decent housing. Today, according to the Abbé Pierre Foundation, 12 million people live in poor conditions.
Farewell, public service?
The Covid could have been an opportunity for awareness. Health is not part of “goods and services that must be placed outside the market”, as Emmanuel Macron proclaimed last March? However, nothing has changed in the hospitals. “After the first wave, a health executive had to justify herself to management, remembers Alice. “How does the Samu regulation service [qui répartit les patients qui arrivent en Samu à l’hôpital, NDLR] Did he allow himself to order so much hydroalcoholic gel?”, he was asked. We had just come out of the first lockdown! » Since then, despite the mobilizations which resumed in the fall of 2021, The answer is always the same: “You had the Ségur [une augmentation de 183 euros net par mois, NDLR], that’s wonderful. And 19 billion euros have been announced to renovate public hospitals. It’s always the same thing: you have to wait. »
Today, the risk is that of a transfer from the public hospital to the private one. “Instead of drawing the conclusion that the public hospital treated 85% of Covid patients and that the private sector was requisitioned and operated as a public service treating all patients, we are told about the failure of the 1945 model”, laments André Grimaldi. However, unlike the public, private clinics (25% of beds and places) sort patients. In critical care, for example, “the lucrative private sector mainly carries out post-operative activity in a scheduled setting with less critical patients”, while the public supports unscheduled stays with a higher level of severity, notes the Court of Auditors . Clinics thus maintain their profitability (+ 0.6% between 2015 and 2016) and the doctors who practice there can increase their excess fees (+ 31% between 2012 and 2017) despite a drop in prices for establishments, further notes the Court of Auditors .
Another means of sorting: geographic concentration in urban areas, where patient-clients are more solvent and consume more care. Overall, the private sector specializes in day surgery, while the public hospital takes care of complex surgeries (trauma, neurosurgery, etc.), as well as infectious diseases, HIV or toxicology. A transfer to the logic of the private sector therefore consists of giving up treating part of the population. As for the private non-profit sector – hospitals managed by mutual insurance companies – it represents 15% of beds and places, its main drawback being that it can be easily taken over by the private sector for profit.
In health however, the price of the act does not make the quality. Which makes André Grimaldi say that“An egalitarian and supportive health system is a chance for the rich to be treated as well as the poor”. But to defend it, you need a balance of political power, as was the case at the time of all the great social conquests.
Find our file “Hospital: investigation into a shipwreck that could have been avoided”