1. Changes in Primary Care Organisation in France Health care Reform Towards multidisciplinary PC settings Best practices Prof. Marianne Samuelson Cyprus European Forum of Primary care May 2009

2. January 2005 Pr M.Samuelson - Pr H.Falcoff - D.Natanson 2 France in a changing process? An important Reform A great challenge.. Towards multidisciplinary Primary care settings

3. May 2009 Pr. Marianne Samuelson 3 Three parts in the presentation < I- Un new law reorganising health care in France. Specific points concerning Primary care < II- Some experiences of organisations of multi professional PC settings < III- Analysis < adapted

4. May 2009 Pr. Marianne Samuelson 4 Some figures < 207 000 doctors/340 per 100000 < Example Paris region 23000 doctors officially 11000 GPs but only 3500 practicing really general practice < So the figures are not a good indicator < Unequal distribution of doctors on the territory < distribution among specialities not adapted < adapted

5. May 2009 Pr. Marianne Samuelson 5 I- A major Heath care reform Crossing point of all expectations… < Modernising hospital < Improving access to good quality care < Defining levels of care and emphasising cooperation between professionals < Emphasizing prevention and public health < Territorial organisation of health care system

6. April 2008 Pr. Marianne Samuelson 6 1-Hospitals and private clinics < Reinforcing public utilities < Improving organisation and governance < Coordination on a territorial basis

7. April 2008 Pr. Marianne Samuelson 7 2- Improving access to care and improving quality of care < Defining levels of care < Adaptation to population needs < Organising out of hours services < Task division between doctors and other health care professionals < Coordinating cooperation between health care professionals < Link between CME and QI procedures towards Continuing Professional Development < Tacking problem of “refuse to give care”

8. April 2008 Pr. Marianne Samuelson 8 3- Prevention and public health < Defining population targeted prevention actions based on national priorities. < Keeping the balance between care and prevention < Patient education :involving patients in prevention and risk management. < A law forbidding alcohol and tobacco selling to teenagers

9. April 2008 Pr. Marianne Samuelson 9 4- A territory based organisation of health care services < A new structure (ARS), based on an integrated organisation of services including PC, hospitals… in place of the old hospital centred organisation < A new governance organisation including the state, health insurers, local authorities, and representative of patients < Definition of regional health policy based on specific health problems and setting of regional strategies

10. May 2009 Pr. Marianne Samuelson 10 ARS a new structure: “Regional agencies for healthcare” < Under the responsibility of the heath ministry < Reinforcing territorial health care policies < Acting at a regional level < Regional policy based on the work of a “regional health conference” < Replacing 7 structures: simplification of the system, multi professional representation < Acting at all levels of care/ previous hospital centred structures

11. May 2009 Pr. Marianne Samuelson 11 As a conclusion: a reform oriented towards the future < Optimising organisation of care for patients < Responsible and well educated health care professionals < Improving territorial organisation < Heath care structures adapted to there missions < adapted

12. May 2009 Pr. Marianne Samuelson 12 Specific steps forward concerning primary care in the reform < Levels of care defined for the first time < Territory based PC settings or organisational models described in the law < Definition of undeserved areas and proposal to attract young doctors to work there < General practice fully acknowledged as an academic procedure and recruitment procedure of academics in place < Task division among PC professionals mentioned < Definition of continuous professional development < adapted

13. April 2008 Pr. Marianne Samuelson 13 II- Concrete territory based PC health care settings already in place < Around one hundred multi professional PC care settings on the French territory < Population based < Focus on quality of care < Emphasising cooperation between health care providers and social workers. < Oriented toward needs of health care professionals ( preventing burn-out, preventing lack of health care professionals in underserved areas…)

14. May 2009 Pr. Marianne Samuelson 14 Different type of organisations < Under the same roof : “ maisons de sante”: professionals sharing the same premises, GP, nurse, psychologist…. < Serving a specific geographical area, or population: “ Poles de Sante”: Functional units working in close cooperation in different sites

15. April 2008 Pr. Marianne Samuelson 15 Common goals… < Serve a population, either rural or underserved suburb population : access of care, continuity, out of hour care… < PC tasks : prevention, health promotion < Focus on quality of care < Training young doctors. < Research and evaluation of practice < Experimenting new payment methods beside the main fee for service system ( capitation, pay for performance…) < Task division among different PC professionals

16. April 2008 Pr. Marianne Samuelson 16 Various type of organisations and governance of these PC settings < Some stimulated by local authorities (mayors, local politicians…) < Some initiated by professional leaders (mainly GPs….) < Some connected to regional policy < Some are very anarchic

17. May 2009 Pr. Marianne Samuelson 17 IIII- Analysis - Connections between experimental organisations and new legislation < Strengths < Weakness < Opportunities < Threats

18. April 2008 Pr. Marianne Samuelson 18 Strengths < Connection between national, regional and local policy < Meeting a real demand to improve quality of care < Emphasising cooperation among health care providers and between them and social workers. < Attracting and educating students on new organisational models adapted to PC practice < Preventing burn out of professionals < Taking more into account patients preferences and needs

19. April 2008 Pr. Marianne Samuelson 19 Weaknesses < Depending on the quality of the leadership < More focused on needs of health care professionals than on patient or population needs < Not specifically located in areas of underserved populations < Difficult cooperation with secondary care

20. April 2008 Pr. Marianne Samuelson 20 Opportunities < Attract doctors and heath care professionals in underserved areas < Reinforcing social cohesion < Definition of new task division < Better use of professional competencies of care providers within PC < Cooperation between different levels of care < Better use of guidelines

21. April 2008 Pr. Marianne Samuelson 21Threats < Only a voluntary base at the moment < Defining undeserved areas < Definition of target population for the various health care professionals < Unclear task division until now, pressure of the various professional groups < Sharing patient information: technical, administrative…. problems < Strong opposition of medical students to any obligation to settle down in underserved areas < Fear of loss of power of hospitals, and medical faculties < Disagreements between unions on payment methods < Fear of pay for performance

22. May 2009 Pr. Marianne Samuelson 22 Some figures < 207 000 doctors/340 per 100000 < Example Paris region 23000 doctors officially 11000 GPs but only 3500 practicing really general practice < So figures are not good indicators < Unequal distribution of doctors on the territory < distribution among specialities not adapted < adapted

23. Merci…