Focus originally published on the website of the Autonomy Health Ideas Laboratory (LISA), of which we are partners.
Let us immediately reassure the reader: we will not give in to the eschatological wave. Yes, there is an urgent need to act resolutely and on all fronts with regard to the health professions! But no, we are not at the edge of the abyssthe system is not about to collapse… And it is not enough to say that the end is near to hide the indigence of certain analyzes or certain proposals.
A crisis unprecedented in its magnitude
The originality of the period comes from the fact that the causes of the crisis are multiple and that this concerns all health professions.
There are hardly any subjects that are not addressed today, most of the time to point out failures: attractiveness of professions, recruitment, training, perimeters of professions and distribution of skills, duration of careers, working conditions and hardship, health at work, career development prospects, end of career… We therefore have a problem of access to resources trained in line with needs and available over time.
Aggravating factor: the questions or difficulties do not simply concern this or that part of the medical or paramedical professions, this or that segment of care. Year after year, all statuses, all levels in the hierarchy of professions, all sectors are concerned. One day the child’s health, another mental health or emergencies, perinatal or old age.
The health crisis has put salt on the wounds. Inflation reshuffles the stakes. Past shortcomings in regulation are debited to public authorities… even when responsibilities are shared (on the issue of numerus clausus for example).
The crisis does not only concern France, which puts everyone’s responsibilities into perspective but only increases the feeling of powerlessness.
Another novelty, annoying this one: the invectives rain down heavily (on the subject of advanced practices and direct access, in particular) and more or less fanciful proposals fuse. The context of negotiation opened up by the medical convention does not explain – and does not excuse – everything.
All this to say that we can no longer reason about these questions in separate worlds. From this point of view, the configuration of health insurance agreements is not, let’s say… ideal. As the Ségur of health in its time was not.
Change stance
The posture of the actors must also evolve very significantly on several points:
Questions from formation are no longer just a matter of trainers or students: steering these issues is an eminent responsibility of the public authorities: strategic forecasting in these matters, quantitative regulation policy, steering recruitment, accreditation and evaluation of training, coordination with continuing education… all of this must be more precisely managed and it is no longer enough here to activate the traditional regulatory weapon. Providing quality and benevolent training has, for example, become an objective for public policies if we want to avoid losses during training or at the end of it…;
For too long, certain subjects have been referred to individual initiative and to the interests of agents, even though they have a systemic dimension and involve the general interest:
This is the case with professional promotion or validation of skills: we will not make the same efforts in terms of political commitment and resources mobilized if we are willing to consider that these mechanisms contribute to the attractiveness of the professions concerned. and therefore the robustness of the organization of the health system; the development of work-study training and the simplification of VAE systems are thus clearly a priority for the health system today;
The extension of the skills of the professionals in post, in a register of advanced practice or specialization – it does not matter here – should not be considered only through the individual benefit that the agents can derive: it is in the interest of the system of build the intermediate skills we need. From this point of view, the “starting delays” experienced in the deployment of advanced nursing practices should serve as a lesson;
The same applies to questions of working and arduous conditions : making it an issue of career sustainability changes the perspective. We know that some nursing careers are terminated prematurely; we also know that there is a subject relating to the employment of seniors, particularly obviously in a context of pension reform. The quality of life at work, the fight against hardship are therefore fundamentally collective issues.
The examples could be multiplied.
Finally, the relevance of such and such a reform on the organization of the system is not necessarily found in the careers of the agents… and vice versa: the increase in skills of such and such a profession does not necessarily reflect on the careers or the positioning of the professions (example, again, advanced practices).
Another way of putting it: taken individually, the reforms are – or end up being – most often considered to be relevant, whether it concerns the implementation advanced nursing practices, Article 51 experiments, profound transformations in the field of training, initiatives in terms of direct access or new capacities for action of caregivers (in terms of prescription or vaccination)… but all this does not lead to a transformation of the system or the careers of agents.
Abundance of initiatives
If we refused in the introduction the too often widespread eschatological vision, it is not only so as not to “despair” of the system and the possibilities of rebound. It is also because many topics have been opened over the years.
Contrary perhaps to other domains of public action, one can even say that public authorities have been particularly prolific.
Each large – or small – Health law (2004, 2009, 2016, 2019…) has embarked on provisions, more or less numerous, on professions. Social security financing laws are not left out. Not to mention legislative proposals… The current period is productive in this area.
The 2015-2016 Grand Health Conference had dealt with HR subjects on an extensive basis, without mobilizing hardly any budgetary resources. Like what, not everything boils down to the thickness of the financial envelope.
The Health Segur has provided significant resources but on a narrower basis, both from the point of view of the issues taken care of and the professions and statuses concerned. Today, we are paying for this deficiency and we must therefore broaden the subject. This is the subject of the debates of the National Refoundation Council – Health component and current agreements between the professions and health insurance: for masso-kinesitherapy and for the medical profession.
Gain coherence and momentum
The common impression is that these initiatives in abundance do not make enough sense and have not produced the expected impacts on the organization of the health system and on the situation experienced by professionals. Several explanations can be put forward:
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Maturation or deployment times are long and the sense of action tends to be diluted along these consultation or regulation-making processes;
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The funding and skills development model is often not revealed. Traditional financing persists, with the associated scales of value, and innovations are struggling to emerge or find a place. “The old world is dying, the new world is slow to appear…”;
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There are many bottlenecks in the conduct of reforms, a phenomenon amplified by shortcomings in inter-ministerial steering;
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The multiplicity of the objects of reform produces an effect of dispersion of public action and of the possibilities of contestation.
It is therefore necessary to gain coherence and momentum. That supposes :
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To build, coordinate, share the underlying vision of the transformations that the public authorities intend to bring: depending on the case, until now, the vision is sometimes assumed (and carried in the speeches of public officials), sometimes killed or deployed at low noise or in a messy way. In other words, you need a vision of the care professions, a plan, a financing framework, a discourse and no longer moving forward masked;
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Simultaneously conduct a set of coherent actions whose scope and meaning reinforce each other: we need a clear roadmap, broken down into action plans (with objectives, deadlines and milestones), embarking in the same movement the various ministerial departments concerned and the other authorities (including the regions), alongside the stakeholders (professionals, users, operators, employers, students, etc.).
You don’t have to look far for the model: let’s look at what we have done in terms of digital health in recent years and take inspiration from good practices and the organization deployed on this occasion.
Read, to go further, the analysis My Health 2027, the great transformation: ten priority projects
(Re)read all of Lisa’s analyzes