Reforms in France

1. Alain Jourdain Professor of health policy Reforms in France

2. Introduction : Health care In EuropePeter C Smith • Cost containment • Gate keeping : the GP, médecin référent • Co payments : le ticket modérateur • Community care Soins primaries SROS3 graduation des soins et accessibilité ARS • Markets and competition • The provider markert Nouvelle Gouvernance • Payment mechanisms T2A tarification à l’activité • Purchasers • Information Classement des hôpitaux • Health technology assessment HASTechnologie médicale • Quality improvement Démarche qualité • Professional improvement certificationV2Formation professionnelle • Incentives for Quality • Patient empowerment Participation des usagers

3. The context : in 2003, 3 reforms (1) hospital

4. (2)Public health act 2004 • Public health policy= Instrument of the STATE to guide, organize its effort to protect, promote and restore the health • In the general population, • Or groups with common features • seeking to redress inequalities • Quantified Health Goals, achievable, with value of commitment. Objectives => specific indicators to measure results and assess: Performance Health System Impact of Public Policy multi-year strategic plan when the coordination of actions and of multiple stakeholders is necessary.

5. (3) Reform of social care • Act for the social and medical institutions (2002) • Act for disabled persons (2005)

6. The health sector in France : • Hospital • GP • Social care • Public health

7. Health in France

8. TODAY :REPORT ON THE REGIONAL HEALTH AGENCIES (ARS) Philippe Ritter A review in 2008 Our health system is based on a robust but fragmented among multiple actors If the overall performance is good, several issues are of weak Health indicators of our country are favorable, but they are margins of significant progression, in terms of avoidable mortality and inequalities The rapid growth of spending is not correlated to the improvement of our health, The limits of our health system to take part in a large organizational problems and insufficient institutional tools The organization of our health system is too compartmentalized and responsibilities poorly distributed, particularly at regional level The diagnosis shows the need for reform of the regional steering of our health system, which must be unified and accountable The need for a unified monitoring at regional level The need for more responsible driving, both health policy and their efficiency

9. TODAY :INFORMATION REPORT to THE COMMISSION FOR CULTURAL AFFAIRS,FAMILY AND SOCIALBY YVES BUR, MP • The answer to the health needs is not organized in the most effective way • a) Health care provision is not sufficiently under control to ensure equal access care of all patients • b) The course of patient care lack of fluidity • c) Prevention remains the poor of the health system • The cost of our health system is poorly controlled and difficult to sustain • a) Our health system has a high cost, which helps her "hospitalocentrisme", and poorly controlled, especially for GP expenditures • b) The growth of health spending is not sustainable without gains efficiency ....

10. TODAY:Report presented by Mr. André FLAJOLET Member of the Pas-de-Calais “Juxtaposition of Unordered structures participating in prevention,professionals dissatisfied, prevention entry by the care, loss of opportunity for those who are distant” France is in bad position compared to its European neighbors in some health indicators 1. Morbidity and premature mortality avoidable high 2. Increasing health expenditures not related to improved health 3. Differences health dug by the progress of prevention in the general population and unequal access to care 4. Access to health except pharmacies officine

11. TODAY :What is proposed: ARSREPORT OF THE COMMITTEE FOR CONSULTATION ON HOSPITAL, chaired by Mr Gerard Larcher • DEVELOP THE RELATIONSHIP BETWEEN THE HOSPITALS AND ENVIRONMENT for MEET THE NEEDS OF PATIENTS AND ENSURE THE CONTINUITY OF CARE Proposals : Improve the adequacy of care by encouraging the redeployment supply between health care and social care Structure coordination of care Developing a coordinated care at local level Improve the organization of unscheduled care

12. The Regional agency for healthARS • The ars is a public institution with the administrative and financial autonomy • It will be headed by a Director General appointed by the Council of ministers • It has a supervisory board • A regional conference of health is responsible for the Definition of the regional health • Two commissions of coordination of policy services involving the state, the collectivity teritorial and social security authorities In the area of • prevention • care • social care • It is under the supervision of the ministers responsible for the health of elderly persons

13. Factors favouring reform : ….since 20 years • Obstacles : independence of the social security GP self employed

14. Example: the improvement of the course of care for older people -- - Fonctions mobilisées au sein de l’agence - Strategy for improvement of care Different sectors of the care Reporting 1 2 3 5 6 7 8 • Monitoring the achievement of outputs • Examples: • Progression of hospitalization at home • Evolution of the number of SSR • ... • Monitoring the achievement of results: • Decrease the number of entries by emergencies, • Decrease the number of multi-input, ... • Improving the health of the population (Health Survey)‏ • ... • Allocations des ressources • … Veille, observation Evaluation de l’efficience Programmation et financement Promotion de la santé Offres de soins Médico-social Suivi / évaluation Observation of care: Type of Emergency Multi-Input Level of medicalisation of SSR and local hospitals Places HAD ... Evaluation of medical-supply Name: Seating capacity and quality of supply EHPAD Observation of health needs: polypathies ... • Structuring of the range of supply as required: complete hospitalization, hospital days, HAS, SSIAD, transport health • Presence healthcare consultations and advances in local hospital • Support filières geriatric hospital - outpatient • ... • Definition and monitoring of the regional scheme medical and social gerontological • Consultation with the Provincial Councils Monitoring the achievement of outputs Examples: Progression of hospitalization at home Evolution of the number of SSR ... Monitoring the achievement of results: Decrease the number of entries by emergencies, Decrease the number of multi-input, ... Improving the health of the population (Health Survey)‏ ... • Costing • Identification of the levers of action: grading of care, inter-institutional coordination, coordination - City hospital, gerontological practice, information for older people more fragile ... • Evaluation of the feasibility and cost of the operations • … • Mobilization of physicians, to regulate entry into the care system • Consultations specific detection of potential disabilities, nutritional, social assessment, ... • Mobilization of professionals to support the return home • . • Appui à la réorganisation d’établissements • Aide à la création de réseaux gérontologiques • Accompagnement des EPHAD • Concertation avec les conseils généraux • Mise à disposition d’information via les collectivités locales Promotion de la qualité (lits anti-escarts, …)‏