The transition from France to stage 3 in mid-March and the launch of the white plan a week earlier brought 500 clinics and 300 private healthcare establishments into the fight against the coronavirus. On March 16, the Minister of Health asked them to de-schedule their interventions in order to significantly increase the capacity for critical care.
At the beginning of April, however, transfers of patients to remote regions, even if there were private structures in their regions of origin, continue to cause misunderstandings among the general public.
You have questioned us many times in the daily “live” of the World and comments to our articles on the recourse deemed too low in the private sector in the management of severe cases of Covid-19. One month after the start of the crisis, we interviewed various regional health agencies (ARS) and private structures to take stock of the situation.
Why collaboration has been slow to establish
If they have common missions, the public and private healthcare systems coexist but do not necessarily work together, each with their own specialties. The private sector (very present in the south of France) does more surgery, and the public more medicine. The latter is responsible for most of the emergency medicine activity.
“In health crisis management plans, public hospitals, which have more resources and generally deal with the most serious accidents, are always on the first line, and clinics on the second line”, explained to Agence France-Presse, at the end of March, Frédéric Valletoux, the president of the French Hospital Federation (FHF, public hospitals).
The SAMU took a little time to change its habits, explaining delays in ignition
In addition, the patient referral circuit is well established, in the public as in the private sector, and habits are tenacious. ” In practice, describes the Northern ARS, it is the SAMUs which organize the regulation of patients who require hospitalization towards public or private establishments. ” However, according to the networks of private establishments, the SAMU took a little time to change its habits, explaining delays in ignition, for example in the Grand-Est region.
Partly related delays “To the habits of work of the SAMU and of the regulation, which orient first towards the public hospitals. They continued to operate like this when the public was overloaded and we had room ”, regrets to Public Senate Marie-Sophie Desaulle, president of Fehap, the federation of private non-profit establishments (managed by associations, mutuals, etc.).
“There are no contact networks like we have in the public, where everyone has their usual network, abounds with Thierry Amouroux, from the National Union of Nursing Professionals. When there is a shortage of beds, you call such a nurse or a doctor in such a facility, to ask “can you take someone?” but we don’t call it private. They are not in our address books. This is changing. “
- ARS authorizations
According to the Federation of Private Hospitalization (FHP), which made the count, since March 20, 99 derogatory resuscitation authorizations have been issued to the private sector (including 64 for the private and 35 for the non-profit); a marked increase in capacity compared to the 298 sites authorized before the crisis… but which took a little time.
Even if the process has been accelerated, it remains mandatory to obtain authorization from the ARS for the creation, conversion and grouping of care activities (whatever the type of care). Certain private clinics have thus benefited from a derogatory authorization for the increase or displacement of their resuscitation services “When possible and safe”, indicate the ARS. Other less well-equipped establishments have been authorized to host “continuing care” (the intermediate stage between conventional care and resuscitation).
Alternative solutions are also being tested: the ARS of Auvergne-Rhône-Alpes has thus made it possible to bring together structures of different status (public, private, private non-profit) in order to pool their forces in a single continuing care unit “Upgraded”. The objective: not to multiply the lines of guard, to concentrate the forces without multiplying the reception sites.
Where are we today?
Over the days, the private sector has been better and better integrated into the system, but it remains mainly used as back-up, for organizational reasons but also for equipment and skills. In Ile-de-France, the region most affected today, 2,500 patients with Covid-19 are treated in various departments of hospitals and private clinics, including 350 in intensive care, according to the FHP. The total number of people hospitalized being 12,681 (including 2,654 in intensive care) as of April 10, the Ile-de-France private sector thus covers less than 20% of hospitalizations (and less than 13% of intensive care).
“It is preferable that Covid patients be treated at CHRU Minjoz, where the premises and equipment are more suitable, and where the staff is better trained for Covid”, assume with East Republican Raphaëlle Remoleur, director of the Polyclinique de Franche-Comté, in Besançon. She recalls that special skills are necessary to manage the resuscitation of patients, fortunately in the minority, who develop severe respiratory distress.
In the private sector, therefore, surgical emergencies (digestive, urological, gynecological, vascular, orthopedic or trauma), and “If this wave exceeds the capacity of the CHRU and peripheral hospitals, then we will take our share here”. Beds have also been opened at the Polyclinic, as well as at the Saint-Vincent clinic, the other large private establishment in Besançon, whose anesthesiologists and intensive care workers are under accelerated observation at the CHRU for “Soak up the specifics of care”.
Following criticisms and misunderstandings from private practitioners regretting that they were not requisitioned, the ARS have set up an organization allowing volunteers to invest themselves and train themselves. Initially launched by the ARS Ile-de-France, the renfort-covid.fr platform makes it possible to mobilize, from students to retirees, all qualified people who could lend a hand to healthcare establishments, but also to Ehpad.
What are the sticking points that persist?
To build a resuscitation bed, explains Lamine Gharbi, president of the FHP, you need a respirator, syringe pumps, medication, a resuscitator, nurses and protective equipment. “There are six parameters: if only one is missing, it’s over. If syringe pumps are missing – this is the case in Paris – resuscitation stops, the same if masks are missing. “
“Public hospitals have other priorities than organizing the dispatch of protective equipment”
The state relies on regional hospital groups (public) to organize in each territory the distribution of masks to all health establishments, adds Mr. Gharbi. “This method of distribution is inadequate and ineffective. Public hospitals have other priorities than organizing the dispatch of protective equipment. “
As the crisis made it creative and allowed them to emancipate themselves from the administrative shackles, other, artisanal solutions have emerged. Jean-Philippe Gambaro, the boss of the Floréal clinic in Bagnolet, says that a WhatsApp group bringing together six public and seven private hospitals has been created. “We chat live, and we try to find a solution between us”, relates Mr. Gambaro.
A new reflex which is spreading, confirms Lamine Gharbi, but which remains insufficient in certain places. “Whatever the quality of cooperation, the subject of protections for caregivers, such as masks or gowns, effectively remains a black spot. “
Why there are still transfers to other regions
The ARS wish to keep some leeway in the event of a worsening of the situation. Transfers, and in particular sanitary trains, are above all a measure of anticipation, explain the authorities: “It’s first to prevent our teams from breaking down and then to avoid reaching 100% occupancy, because the day we are full, we are blocked”, explains Anne Muller, director of health services at ARS Grand-Est. “We try to solicit as late as possible people whose specialty is not. But nobody will cut it, unfortunately “, said a spokesman for the ARS Ile-de-France.