The summer of 2024 once again revealed the degraded mode of medical emergencies in France, demonstrating that the measures introduced in recent years have not solved the basic problem. As with other healthcare sectors, the solution requires systemic reform which is within our reach.
[Un article de The Conversation écrit par Frédéric Bizard – Professeur de macroéconomie, spécialiste des questions de protection sociale et de santé, ESCP Business School]
The last link of care is cracking
The “wall of shame” installed in front of the emergency room at Brest University Hospital this summer illustrates the consequences of the disorganization of emergency services in France. Among the patients over 75 years old in the emergency rooms of this university hospital from July 10 to August 20, 2024, more than 130 spent more than twelve hours on a stretcher, and around forty more than 20 hours.
In order to objectivize the situation, the studies department of the Ministry of Health provided national insight into the operation of emergencies from the 719 existing reception points, distributed in 612 hospitals and clinics. The study covers the same day of activity, June 13, 2023, i.e. outside the most complex periods, concentrated in winter with epidemics and in summer with holidays.
On that date, 54 emergency departments (8%) reported having had to “completely” close their doors at least once in the three months preceding the survey, most often at night. Nearly a quarter (23%) had to set up so-called “regulated” access at least during certain time slots, the regulation consisting of filtering access to emergencies by asking all patients to call in advance on 15 19% of services revealed a lack of doctors to fill schedules.
According to SAMU-Urgences de France, 163 services (25%) had to close in the evening, at night, on weekends and 167 SMUR (mobile emergency and resuscitation service) during the summer of 2023. The figures from the summer 2024 are not yet available but the “wall of shame” in Brest shows that the situation has hardly improved.
However, with around ten reports published since 2013, the case of emergencies should be fully understood by public authorities.
A constantly increasing increase in visits to emergency rooms
With an estimate of 21.6 million visits in 2022 compared to 18 million in 2012, the annual increase in volume of visits to emergency rooms has been 2% for 10 years, knowing that the number of visits has decreased since Covid. Nearly 40% of visits only result in a medical consultation and 22% in hospitalization.
Knowing that 24% of patients represent 61% of visits, emergency room saturation is concentrated on a fairly small number of patients, who go to the emergency room on average 5 times per year, with a median time between two visits of 40 days!
These approximately 3 million regular patients are mainly elderly people with multiple pathologies, users who have no other medical recourse nearby, as well as socially excluded people.
Useful sectoral measures but low impact
The multiple reports on the state of emergencies all make more or less the same recommendations. First, we must provide financial resources for emergencies commensurate with the increase in activity. However, this principle of proportionality, necessary in the short term, is suicidal in the long term for the public hospital, as it puts pressure on other services and does not resolve the structural causes.
The lack of medical resources is explained, among other things, by a share of part-time work increasing from 46% in 2013 to 77% in 2019, and by a change in hospital working time legislation, which, with constant organization, imposes an additional need for emergency doctors of 20% in full-time equivalent. Instability and tension in human resources generate a vicious circle of deterioration in working conditions, which in turn generate resignations, which worsen the situation.
In 2018, the Minister of Health Agnès Buzyn played the “emergency overhaul pact” card, and promised to release 750 million euros for a dozen measures over three years. Among these, the “minimum daily bed requirement” (BJML), intended to ensure emergency doctors have a sufficient number of beds downstream. Currently, emergency workers are still waiting for this very technocratic system to materialize.
Since the Flash mission of June 2022 entrusted to emergency doctor François Braun, who held the position of Minister of Health for a year to apply his recommendations, a system for regulating emergencies by the 15th was established at the end of 2022, then extended to this day. This regulation has been developed at the entrance to certain emergency services and for access to care services (SAS), allowing the SAMU-SAS to organize itself with community medicine to respond to non-vital emergencies.
The “Braun pack” also included upgrades to care by private doctors and the establishment of “access to care services” (SAS), which respond to requests not relating to a life-threatening emergency.
These measures were supposed to relieve hospital services, which they did, resulting in a drop in emergency visits estimated at 15% in 2024. However, the disorganization of services is so profound that the effects felt on the quality of support are inapparent, or at least, are not enough to reverse the negative trend.
All of these measures have in common that they attempt to resolve the issue of emergencies without structural measures, by providing more financial resources and imposing more coercion on patients. However, the facts are stubborn: they demonstrate that this sectoral approach is necessary but insufficient.
The emergency crisis, a mirror of the health system crisis
The gateway to the hospital, the most strategic link in the management of acute vital risk, emergencies are at the crossroads of “upstream” care difficulties – with medical deserts worsening in many territories, “in situ” – with reception and care difficulties within emergency services, and “downstream” – with an insufficient number of beds to hospitalize patients.
However, the essential thing is elsewhere. The emergency crisis is the mirror image of the collapse of our health system: in the city, in hospitals and in the medico-social sector. The triple demographic, epidemiological and technological transition has derailed our health system, which was so efficient in the 20th century.e century and so declining since the dawn of the 21ste century.
Based on foundations laid in 1945 and 1958, it is neither adapted to the management of maintaining good health, nor to that of chronic pathologies, nor to the rapid and massive integration of technological and therapeutic innovations. The current crisis is therefore no accident.
Only systemic reform will resolve the degraded situation
To make sectoral emergency measures impactful, public authorities must become aware of the absolute need to quickly overhaul our health system. President Macron launched a National Council for Health Rebuilding in September 2022, which produced nothing. Research institutions like the Health Institute have developed a comprehensive, turnkey plan for restructuring policies.
The proposed new health model is an adaptation of the existing system to the new environment of the 21st century.e century, respecting fundamental values and integrating all existing stakeholders, while adapting their activities to the new world.
For example, three systemic measures would make the management of hospital emergencies lastingly fluid.
The first would be the establishment of a territorial public health service, delivered by private and public health professionals, on the scale of some 300 health territories covering the entire country. This service would include essential prevention and care missions, including ongoing care and emergencies. It would give all these professionals responsibility for the population and public health of the inhabitants of the territory.
The second would be the flexibility of the professional careers of hospital practitioners and paramedical staff, opening them the possibility of working part-time in the hospital and the rest of the time in the health area. A 5-year service obligation contract would make it possible to adapt the organization of each employee's tasks according to their aspirations and needs. This opening of the hospital walls would allow a number of salaried professionals to work in the city in unscheduled care centers, drastically reducing (target of 40%) the transition to hospital services.
Finally, the reorganization of the hospital would see, among other things, governance with a medical and administrative duo (as in the anti-cancer centers), which would largely delegate decision-making and the management of human and financial resources at the service level. . This empowerment of professionals would give meaning to their mission and would see greater anticipation, in services, of changes in health needs thanks to contact with the field.
“Nothing is possible without people, nothing is sustainable without institutions,” wrote Jean Monnet. This observation applies to emergencies and health: in emergency services as in other specialties, France has health professionals whose quality is recognized throughout the world; it is the institutions that are faltering.
As long as the hand of public authorities remains trembling in the face of overhauling the architecture of the system, its components will malfunction. And in particular emergencies, which are the ultimate receptacle for all these dysfunctions…
With an unwavering passion for local news, Christopher leads our editorial team with integrity and dedication. With over 20 years’ experience, he is the backbone of Wouldsayso, ensuring that we stay true to our mission to inform.
