Hospital, patients, health, territories

Hospital, patients, health, territories is the official name of a French bill presented on 22 October 2008 by Roselyne Bachelot, minister of Health, Youth, Sports and Associative Life. The bill is commonly called bill HPST (acronym of the French phrase) or bill Bachelot. The bill is the first stage of the Hospital 2012 Plan, launched by French President Nicolas Sarkozy, which aims at revamping of the French health care system. The bill aims at guarantee a better and equal access to care for all French people, whatever their geographic location. This reform needs a complete overhaul of the hospitals organization, which caused strong protests among the staffs.
Initial project.
The bill contains four main points, as defined by its official title. It would modernize the hospitals, giving them more financial means to carry out their mission and rehauling their territorial and internal organization. It would also favor research and education. To guarantee a better access to care, it would reorganize the provision of care through a coordination between the hospitals and cities. The bill would also organize it at a regional level. It would finally reinforce prevention against all addictions, especially for young people and women.
The bill focus on measures to improve the health of young people. Minors (less than 18) would be forbidden from drink alcohol, and encouraged to eat fruits and vegetables.
The bill would favor a better access to good quality care by implementing a better distribution of doctors among the national territory. The provision of care would be organized at a regional level. There would be financial incentives in regions lacking health care to appeal doctors. Practitioners of the private sector fear the bill would limit their freedom of installation.
Asserting that there is currently no defined executive power in hospitals, the bill finally implement strong decision-making authorities. In hospitals, directors will therefore see their powers strengthened at the expense of the boards and local elected officials. They will control the hiring of doctors, and their pay.
The opening of frontiers between hospital medicine and city medicine is a more polemical point. The bill would cause the mergings and reconversion of many hospitals, and the specialization of cares provided by some hospitals. Resources and technical means would be polarized in major hospitals, while small structures are encouraged to find other orientation and to specialize, notably in rehabilitation of disable people, and in the care for the elderly. Also, private organizations will be force to provide their care to any people, acting as a public service.
On a larger scale, regional health agencies will be implemented. They would centralize powers currently exercised by health agencies such as Regional Hospital Agencies (ARH), the Ddass or Health Insurance. Led by the regional prefects, they would manage the overall delivery of care, whether private, hospital or medico-social.
Immediate reactions.
Professionals and health care users have reacted to the bill Bachelot.
Reactions over the modernization of the system were rather negative. The trade union Sud-Santé have expressed concerns about the future of the French health system, arguing the law would submit it to capital gains. The organization denounced the dismantling of health public service and the privatization of health care institutions. The Confédération des syndicats médicaux (CSMF) greeted the expected reform of the hospital brought by the bill, which would finally reorganize and modernize the whole system, but denounced the "nationalization" of the health system, arguing the future regional health agencies will be omnipotent. The CSMF proposed various amendments. The Coordination to defend public hospitals declared they were satisfied by the modernization of the system but feared the bill would liberalize the provision health care.
There was also discontentment about the reorganization of the system on a regional level (creation of ARS). The National Coordination Committee for the Defense of hospitals argued the reform would worsen the unequal access to care, depriving a portion of the population from health services. They condemned the closure of hospitals planned by the bill. The Interassociative Committee on health (Ciss) approved of the end of little structures, judged as dangerous. The organization is dubious about the quality of care provided by these establishments.
The measures to improve the access to care were also subject to controversy. The National Federation of Workers and disabled (FNATH) approved of the reform of the hospital, but They announced they would propose amendments to ensure the presence of representatives of patients in the supervisory boards of the hospitals. Practitioners fear the bill will liberalize the system with financial constraints for them. There was a massive rejection of the bill by both private-sector and public-service practitioners. The CSMF said the bill would impose a "tax" for medics working in densely populated regions with many infrastructures and resources. However, the Hospital federation (FHF) have fully approved the measures for medics.
The measures on alcohol were less polemical. The FNATH expressed their disappointment, having expected measures about health at work. The National Association of prevention of addictiveness and alcoholism (Anpaa) has given its full support to the measures limiting alcohol for young people.
Evolution and debates.
Following the legal procedure in France, the bill was first examined by the National Assembly, then by the Senate.
Discussions in the National Assembly.
The discussions in the National Assembly started on 10 February 2009 and ended on 18 March.
Some deputies expressed their reserve about the partnership public-private, fearing the participation of the private sector to the public service would be a privatization of the provision of care. The initial bill proposed that the directors of the Health Regional Agencies (to be created by the bill) would be the persons in charge of entrusting missions to private clinics in case of deficiency. The deputies approved of this measure. The initial bill proposed the creation of a statute for private clinics entrusted with public service mission, but an amendment modified this status. The initial status "private participating to the hospital public service public" (PSPH) was replaced by "private health institution of collective interest". The Assembly also approved of the new way hospitals would be managed. They will be overseen and will have to publish annual reports on the quality of the care provided.
In March 2009, the Parliament debated on the consequences of the prevention plan provided by the bill. Roselyne Bachelot tried to convince the deputies to spare advertising agencies, arguing that firms of other countries have no restrictions. While a report on obesity had been issued in September 2008, the deputies rejected an amendment banning advertisements during television programs for children.
The National Assembly voted the interdiction to sell alcohol to people under 18, against 16 previously, but it officially authorized advertising of alcohol on the web: advertisers are allowed to advertise alcohol on the web and fat and sweet food on television in any program. However, websites dedicated to young people are excluded from this authorization, and also sport associations websites. In addition, advertising will have to be neutral and not intrusive (pop-up, for example). The assembly voted on an amendment to adopt this decision. The Assembly also decided to approve of the fight against binge drinking.
The Association for the Prevention in Alcohol and Addiction (Anpaa) and the French Society of Public Health (SFSP) disapproved of the decision about advertisers, arguing advertising is the major cause of child obesity. They denounced the inconsistency of the bill, which does not implement any restriction, and criticized the influence of lobbies. In particular, representants of the wine industry had expressed their concern about the bill. On 3 March, 23 scientific societies and 17 associations had signed an appeal to parliamentarians to restrict advertising in television for children.
This point is the most polemical of the bill, for it imposed regulations for practitioners. After much debate, the deputies ruled the liberty of settlement would be preserved for medicals. Medicals of regions with important resources would be incited to move to disadvantaged areas. However, they will have financial sanctions ("contributions of solidarity") if they refuse. Medicine students would receive incentives if they choose to settle in disadvantages regions. The Trade union of Liberal Medical (SML) had proposed amendments to guarantee the liberty of settlement for practitioners. The SML said the medicals would be controlled by powerful ARS, and wrote a letter to Roselyne Bachelot. The CSMF criticized the financial sanctions the bill would impose, and call them the "Bachelot tax". They proposed amendments to avoid the imposition of a "numerus closus" for medic by the ARS. They said the bill threatened the profession., and declared they very disappointed the "Bachelot tax" was maintained. The organization (which is the first trade union of practitioners) accused Rosely,e Bachelot of wanting to destroy their profession.
Discussions in the Senate.
The official discussions started on 11 May, but a senatorial commission had examined the bill previously. Another discussion is to take place on 20 May.
The senatorial commission release a report, called the "Marescaux report", which proposed various amendments on the title I of the bill, i.e. on measures regarding the reform of the hospitals centers. The report focused on the management of hospitals and criticized the overwhelming power the directors of hospitals would get with the bill. The report said the executive must not be concentrated in the hands of one single person. physicians regarding the governance of the centers. It recalled the three missions of hospitals: teaching, research and care, and said medicals, teachers and researchers should participate in the management of care centers. The government proposed amendments following this report.
The trade union of private sector medicals (SML) have proposed 40 amendments aiming at promoting the professional liberties for medicals. The amendments included the suppression of the "Bachelot tax". Most of the amendments were approved of by the senators. The CSMF also proposed amendments, notably to remove the "Bachelot tax".