In France, the health system is based on a social security model that covers the contingencies of illness, work accident and occupational disease. It was born after the Second World War and covers all social insureds. It is financed by compulsory contributions paid by companies and employees, both public and private, and by a social contribution that taxes salaries. We could say that the model is similar in its foundations to Spanish prior to the health reform that created the National Health System in 1986.
Health spending represented 12% of GDP in 2009. The health benefit represents approximately € 3,100 per citizen per year. The average progression of health spending in the last 10 years is of the order of 5%.
The ratio of medical specialists to generalists is, in France, 1 to 1, which may indicate the social influence of the latter. The number of deputies in the National Assembly who are doctors by profession may be around 50.
The health system
We can say that the French health system has two major areas of provision of health services, ambulatory care and hospital care. Ambulatory care is guaranteed by private providers, practically in their entirety, who are convinced by social security that they exercise a liberal profession. This National Convention regulates in detail the benefits that will be provided by each professional (doctor, nurse, physiotherapist, dentist) who keeps his status as an independent professional but agrees to work for a fee negotiated by the respective professional unions. The “convincing” family doctor (practically the whole) charges a fee currently set at € 23 for the consultation, € 33 for the visit, to which are added the travel expenses also set in the Convention. These posts increase during night, holiday, etc.
Likewise, the amounts of a detailed catalog of codified technical acts that can be performed by the family doctor in their usual practice, such as infiltrations, fracture reductions, cryotherapy, small surgery, sutures, etc., are set. This comprehensive exhaustive catalog can be done, in principle, by any family doctor who feels qualified for it. The payment of fees for a medical act is made by each patient. 70% of the total will be reimbursed by the social security later and the remaining 30% by a complementary mutual fund if the patient has it. Most patients have a mutuality, which they choose freely and pay monthly or annually.
There are patients with a chronic pathology (from a list of 30 ALD or “long-term condition”) that are exempt from the advance of the medical fee for acts related to this pathology. In these cases, the doctor is paid directly by the social security of the act in question. Hospital care is, to a large extent, public. Its staff is recruited by competition, frequently at the initiative of the health authorities, and is salaried with a statute equivalent to our staff of hospital staff, that is, quasi-functionary.
Private hospital care is mostly concerted with social security, but its doctors are autonomous, they receive “agreed” fees but with the possibility of overcoming them with “tact and restraint”. The system is based on the freedom of choice of doctor and hospital by the patient. This freedom is well anchored in the mentality of citizens and is exercised without any type of complex. The freedom of the doctor to accept the patient is also exercised naturally.
Until a few years ago, the system of access to the doctor, both family and other specialties, was totally free. In spite of this, the vast majority of patients had their GP, called «médecin traitant». Right now, if the patient wants to be reimbursed for his consultations, he has to respect the so-called «parcours de soins». For this, you have a “traitant” doctor, that is, one who is in charge of primary care (it does not have to be a family doctor, although it is in most cases), which is the one that can be used by other professionals. . This family doctor has, then, a list of patients who have chosen him and for those who constitute the entrance to the system. Patients under 16 years of age do not have this limitation.
Coordination / relationship with secondary care
This is one of the chapters in which France, for a family doctor, is an idyllic place. Taking into account that the provision of outpatient specialized medical services is private and the tradition of this situation in the French medical body, the reports that the specialist sends you (always) when you have seen one of your patients begin …
“Dear colleague: Thank you for allowing me to examine your patient ….” This says it all. The specialist treats the family doctor as a client being his provider and this changes everything with regard to the situation in Spain in the public sector. Of course, the family doctor chooses the specialist he considers most appropriate for his competence, availability, behavior with patients, etc., and with that he weaves a network of correspondents with whom he works in total harmony and fellowship. The specialist proposes, “with your agreement”, a treatment of any kind and the “traitant” doctor whose term means “treating” his patient is the one who has the decision of the treatment he discusses with the patient.
In the hospital services, discharge reports are always sent to the family doctor, who is often contacted by telephone to announce the discharge of his patient. The continuity of care is demanded by the patient himself and he is the first to desire it because of the key role of his family doctor when he returns home. And if the process is not going well in his judgment, the patient does not see that doctor or that hospital or that service again. The family doctor is socially respected, his work is considered to be of great value and his time is precious.
Continuing education and professional reaccreditation
The French family doctor is considered a specialist since January 2005. Access to the specialty is via MIR exam, at the end of 6 years of faculty. The duration is 3 years with rotations in hospital and in cabinets of general medicine with accredited tutors. To practice as a liberal professional it is necessary to be a doctor of medicine, but your doctoral thesis would be comparable to our bachelor’s thesis.
Continuing education is included in the National Convention, which allows family doctors to participate for 8 days a year in regulated practical training activities organized by medical associations. A compensation for loss of fees of € 15 (code representing the consultation established at € 23) per training day is included. They are usually 1 or 2 days, Saturday or Friday and Saturday. The pharmaceutical industry participates in the financing of associations of FMC (continued medical training) that are very numerous. In Lavit de Lomagne we have an association of FMC in which fifteen doctors participate and we meet about 8 or 9 times a year for FMC sessions, which we decide ourselves with total autonomy for the subjects and the speakers.