Bonjour,

Nous publions aujourd’hui un document. Et nous le publions dans sa version princeps, celle du Lancet (daté du 29 mars), faute de disposer encore de sa traduction certifiée en français (1). Mme Touraine signe son texte en tant ministre des Affaires sociales et de la Santé. De fait elle l’avait adressé avant la démission de Jean-Marc Ayrault et la constitution du premier gouvernement Valls. Gouvernement dit « de combat » dans lequel, on le sait, son titre a été « resserré » et amputé de la Santé.

Pourquoi The Lancet ? Sans doute parce que ce titre vieux (190 ans) et prestigieux, dirigé par Richard Horton propriété du puissant groupe néerlandais Elsevier, se passionne de longue date pour les questions d’égalité dans le domaine de la santé. Elsevier (7000 collaborateurs) contesté pour sa politique de prix profondément inégalitaire.

Une bénédiction laïque

Cette publication est une bénédiction laïque et politique. D’abord parce que le président de la République entend faire de la « Santé » l’un des piliers de sa nouvelle politique. Il l’a dit lors de sa dernière intervention télévisée. Ensuite parce les communicants proche du Premier ministre ont dit que ce dernier traiterait de Santé dans son premier discours de politique générale programmé pour le 8 avril. Enfin parce que le prochain secrétaire d’Etat en charge de la Santé n’aura plus qu’à s’inspirer de ces deux éléments (le papier du Lancet, le discours du Premier ministre) pour écrire sa feuille de route. Rien moins que mettre en place « un nouveau contrat social afin d’encourager le développement, la durabilité et l’équité du système de santé français ».  Et ce via une nouvelle loi.

Provocation française

« France’s national health strategy » ? « Stratégie nationale de Santé »  ? On verra ce qu’il en est ici. Le papier du Lancet met en lumière des éléments qui nous avaient échappé. A commencer par ces 150 forums qui, de novembre 2013 à mars 2014, ont réuni 23 000 personnes à travers le pays. Les lecteurs non français du Lancet percevront-ils comme une provocation ce rappel que la France a le meilleur système de santé au monde, que les usagers en sont globalement satisfaits mais qu’il entend désormais l’améliorer afin d’en réduire encore les inégalités ?

Jean-Jacques

Un nouveau « contrat social », donc, ce qui n’est pas une mince affaire, comme l’histoire de France nous l’a enseigné. Une entreprise qui concernera l’ensemble du gouvernement. Une entreprise qui sera radicalement différente des actions qu’ont pu (ou non) mener  Xavier Bertrand, Roselyne Bachelot, Philippe Bas, Philippe Douste-Blazy, Jean-François Mattei, Dominique Gillot, Bernard Kouchner, Hervé Gaymard ou Elisabeth Hubert, pour ne pas remonter avant 1995.

Ambition politique paradoxale

On retiendra notamment ce qui ressemble fort à un engagement concernant l’Open data sur les données sanitaires : (…) facilitating access to health-care data. (…). On retiendra aussi, au final une ambition politique assez paradoxale : persuader les français que l’on peut encore améliorer, au nom de l’égalité, un système de santé dont ils sont persuadés (cf une étude du célèbre cabinet Deloitte) qu’il est le meilleur au monde. Attendons désormais ce que nous dira sur tout cela le nouveau Premier ministre.

A demain

(1) Ce texte est paru dans l’édition du Lancet datée du 29 mars sous le titre « Health inequalities and France’s national health strategy ». Seule signataire  Marisol Touraine a   Le voici :

“Around the world, rising health-care costs are claiming an increasing share of national budgets. In September, 2013, the French Government launched a comprehensive national health strategy to address financial issues under national health insurance, health-care reform, public health issues, and social aspects of health inequalities. This strategy will inform preparations for a new health law to be presented to parliament before the summer. This will be the first time that a French law will address both issues related to public health and to health insurance and reimbursement. To prepare the content of the law, I initiated public forums throughout the country, and from November, 2013, to March, 2014, there have been 150 public forums involving 23 000 participants.

A key goal of the new strategy is to tackle health inequalities that are rooted in social determinants. The French health-care system is often seen as one of the best: it ranked first of 191 states in WHO’s World Health Report in 2000.1 Indeed, compared with the regional average in Europe, France has higher life expectancy (82 years vs 79 years), lower maternal mortality ratio (8 per 100 000 livebirths vs 20), and spent about twice as much of per capita total expenditure on health.2 However, as in other countries, there is evidence of substantial and increasing health inequalities in France,3 and so far there has been no comprehensive policy to reduce them. There are more inequalities in death rates in France than in many other European countries, particularly for men, and these inequalities have increased in recent years.4 Inequalities in quality of life as a result of diverse disabilities are another cause for concern. The inequalities in death rates and quality of life concern virtually all diseases, risk factors, and states of health.

In its report on health inequalities, the French High Council for Public Health5 highlighted how this issue has been addressed from the sole perspective of personal care in the context of patient—doctor relations. Hitherto, the French debate on health inequalities has largely focused on access to health care under the health insurance and social protection schemes. The French health-care system combines universal coverage with a public—private mix of hospital and outpatient care. Although indicators of health status and consumer satisfaction are high, reform is needed to tackle the chronic financial deficits incurred by French national health insurance.

Several recent policy developments have improved financial accessibility to health care for the poor. Under the national health strategy, universal coverage is to be strengthened with a particular focus on universal access to supplementary insurance. Nevertheless, achieving universal coverage has not prevented geographical disparities in the distribution of health resources and unacceptable variation in health outcomes according to socioeconomic status.4, 5 There is a broad consensus that these issues extend beyond financial and organisational aspects of the health-care system and require stronger public health interventions and a multisectoral approach.

One of my core commitments under the national health strategy is to promote a new social contract across the whole of government to foster the development, sustainability, and equity of the health-care system with the aim of not only improving performance indices but also reducing health inequalities. Under this social contract, every government department will be accountable for the impact of their policies on public health and health inequalities. The social contract will ensure a strong focus on the social determinants of health inequalities.

Redesigning the organisation and delivery of health services is the second main goal of the national health strategy. Rationing services to contain health-care costs is unfair and counterproductive. My strategy for the French universal health-care system will take a different direction from that of my predecessors. I want to make health services more efficient by reforming the system of payments to providers, fostering interdisciplinary team practice, reforming the delivery system, strengthening health information to help consumer choice, and facilitating access to health-care data.

Another key part of the strategy is to strengthen primary care services and the coordination of care, especially for patients with chronic diseases and older people. Local initiatives should be strengthened. For instance, the experimental programme “Asalée” was launched in 2004 and facilitates cooperation between nurses and general practitioners in outpatient management and follow-up of patients with type 2 diabetes. Given the success of this local initiative in terms of improved quality of care for these patients, I decided to accelerate wider implementation of this programme.6 There have also been calls to replace the current fee-for-service payment system with one in which providers share risk for the cost and quality of services.7 These alternative models include capitation and create incentives to providers so that they avoid unnecessary care and deliver higher value services. The French health-care system is well positioned to accelerate transformation to high-value models of advanced primary care. The Regional Health Agencies are responsible for ensuring that health-care provision meets population needs by improving coordination between the services provided by outpatient and hospital sectors and the health and social care sector, while meeting national spending targets for health. The national health strategy will reinforce the activities of the Regional Health Agencies by allowing more flexibility in resource allocation and adjustment of national policy to the local context and environment, especially with regard to primary care.

France benefits from the strong commitment of its health professionals. The new generation of doctors expect improvements in working practices, for example, promoting a team-based approach in community care to streamline the delivery of care and expanding the role of health-care workers, such as physician assistants or nurse practitioners, who can undertake tasks that do not require physician-specific skills. Wider use of technology, such as developing electronic health records, particularly for patients with chronic diseases, is also a priority of the national health strategy.

There is a broad consensus that innovations will drive the 21st-century economy. The e-health innovation sector, the biotechnology industry, and the life sciences sector are powerful parts of the French economy. The French Government has identified the biotechnology industry as a strategic sector for the future and invested €2·95 billion in health and life sciences research programmes in 2012.8 Innovation will be crucial to the future of health care in France. One of the main goals of the national health strategy is to foster clinical research programmes so that France will regain its international leadership position. The reform of health care through the national health strategy will be innovative, efficient, and fair. Although many French people believe that their health-care system is superior to that of most other countries,9 my ambition is to enhance quality and equity in health and to preserve our exceptional national assets.

MT is Minister of Social Affairs and Health, France.

References

1 WHO. World health report—health systems: improving performance 2000. Geneva: World Health Organization, 2000.

2 Organisation for Economic Cooperation and Development. Country statistical profiles: key tables from OECD. Country statistical profile: France 2013. OECD iLibrary. http://www.oecd-ilibrary.org/economics/country-statistical-profile-france-2013-2_csp-fra-table-2013-2-en. (accessed March 1, 2014).

3 European Commission. Health inequalities in the EU—final report of a consortium, consortium lead: Sir Michael Marmot.Brussels: European Commission Directorate-General for Health and Consumers, 2013.

4 Mackenbach JP, Stirbu I, Roskam AJ, et alEuropean Union Working Group on Socioeconomic Inequalities in Health.Socioeconomic inequalities in health in 22 European countries. N Engl J Med 2008; 358: 2468-2481. PubMed

5 Lang THaut Conseil de la Santé. Les inégalités sociales de santé: sortir de la fatalité. Paris: Haut Conseil de la Santé, 2010.

6 Government of France. Loi no 2013—1203 du 23 Décembre 2013 de Financement de la Sécurité Sociale pour 2014; article 35 (in French). http://www.legifrance.gouv.fr/affichTexte.do?cidTexte=JORFTEXT000028372809. (accessed March 6, 2014).

7 Cordier A, Chêne G, Duhamel G, et al. Un projet global pour la stratégie nationale de santé. June, 2013 (in French).http://www.social-sante.gouv.fr/IMG/pdf/rapport-cordier-SNS-sages.pdf. (accessed March 5, 2014).

8 Cour des Comptes. Le financement public de la recherche, un enjeu national—Juin 2013. 2013. (in French).http://www.ccomptes.fr/fr/Actualites/A-la-une/Le-financement-public-de-la-recherche-un-enjeu-national. (accessed March 5, 2014).

9 Deloitte. Etude santé les Francais et la santé. January, 2012 (in French). http://www.deloitte.com/assets/Dcom-France/Local%20Assets/Documents/Votre%20Secteur/Sant%C3%A9%20et%20sciences%20de%20la%20vie/20120117%20-%20Presentation%20Etude%20Deloitte%20Sant%C3%A9%20France%202011.pdf. (accessed March 5, 2014).