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19 December 2016 | Country Update
Termination of restrictions to receive hospitalization at home (HAD) in retirement homes -
28 September 2016 | Policy Analysis
Changing the hospital landscape: integrating public hospitals to improve efficiency -
06 June 2016 | Country Update
Territorial Hospital Groups
5.4. Specialized ambulatory care / inpatient care
Acute medical, surgical and obstetric care is provided by public as well as private hospitals, with different areas of specialization.
Acute medical care is mainly provided by public hospitals, which account for nearly two-thirds of acute medical care capacity (67% of medical beds and 50% of day-care beds) and are responsible for 65% of full-time episodes and 42% of day-care episodes. Private profit-making hospitals account for 25% of full-time beds and 40% of day-care beds, and they provide 27% of full-time episodes and 50% of day-care episodes; they specialize in a small number of technical procedures for which there are profit opportunities, such as invasive diagnostic procedures (e.g. endoscopy or coronary angiography). The balance of acute medical activity is performed by the private non-profit-making sector, which are the main providers in the area of cancer treatment (see section 4.1.1).
Delivery of surgical care is divided fairly even between public and private profit-making hospitals, although the latter performs 67% of the surgical episodes in day-care settings. Surgical care accordingly represents more than half of the acute care activity of the private profit-making sector. These hospitals tend to specialize in procedures that can be performed routinely within a short stay with a predictable length. Public hospitals perform a much wider range of surgeries than profit-making hospitals, including the most complex procedures. Surgical procedures performed in the private non-profit-making sector are mostly related to cancer treatment, as for medical stays. Finally, two-thirds of obstetric procedures are performed within public hospitals, while the private sector accounts for the remaining third, mainly within profit-making hospitals (one-quarter of all obstetrical stays).
Since 2008, policies to encourage ambulatory surgery have been successfully implemented, resulting in growth in all three hospital sectors: +17% in the public sector, +22% in the non-profit-making sector and +11% in the private sector. The last accounts for the largest share, with 70% of ambulatory surgeries taking place in private hospitals in 2011. Nonetheless, at nearly 40%, the overall rate of ambulatory surgery in France remains lower than in neighbouring countries; for example, the share of ambulatory procedures was 52% in Germany and 74% in Denmark in 2009 (Toftgaard, 2011). The French Government has set a target with the ARSs for ambulatory surgeries to exceed 50% by 2016 (DGOS, 2012).
Reforms of the hospital sector have consistently supported greater managerial autonomy of public hospitals. The 2009 HPST Act has increased the autonomy of public hospitals and their organizational flexibility and clarified their internal decision rules. Executive responsibilities, which were previously held by the administrative board (conseil d’administration) of the hospital (comprising representatives of the state, local authorities, hospital staff, patients and qualified personalities), are now held by the hospital director; accordingly, the remit of the administrative board, which has been renamed the monitoring board (conseil de surveillance), has been reduced to defining hospital strategy and controlling its implementation. Decisions directly relevant to the quality and safety of patient care are jointly taken by the director and the president of the hospital’s board of physicians (commission médicale d’établissement).
While regional disparities in acute care capacity have significantly diminished in recent years, disparities regarding human resources in acute care remain. Moreover, continuity of care between the hospital and ambulatory sectors is a particular challenge. Lack of coordination between inpatient and outpatient care may result in unnecessary rehospitalization. To address this problem among frail elderly persons, the ministry in charge of health has launched regional pilot projects to develop and test tools for improving coordination of care in this population (see section 6.1.4).
Since 2007, hospitalization at home (hospitalisation à domicile, HAD) has been extended to retirement homes and other residential facilities, notably residential accommodations for people with disabilities since 2012. However, the provision of HAD was subject to specific restrictions for certain types of interventions, such as respiratory assistance, palliative care or blood transfusion. Those restrictions applied, for example, if those interventions required the presence of additional staff during the night or were not associated with another intervention. Starting from March 2017, the provision of HAD services for frail elderly people in retirement homes will no longer be limited and restrictive conditions which were previously necessary will not apply any longer. The aim of this measure is to better take into account the needs of frail elderly people by ensuring that HAD does not represent a type of care by exception, but the norm in retirement homes.
More information (in French): http://social-sante.gouv.fr/IMG/pdf/16_12_07_cp_had_ehpad.pdf
Authors
Context
1100 French hospitals will be re-organised in approximately 150 territorial hospital groups (groupements hospitalier de territoire, GHTs), according to their geographic location. The GHTs will formalise the various partnerships between hospitals and will change dramatically hospital markets, transforming how hospitals function.
Impetus for the reform
GHTs constitute one of the key provisions of the Law of 26 January 2016 (article 107) on the modernisation of our health system (see Health Policy Update 02/07/2015), which was presented by the current Ministry of Health as an “innovation that will strengthen the public hospital service”. The GHTs are considered channels to encourage cooperation between health care facilities, to improve the management of resources and, ultimately, to downsize the hospital sector, which represents a higher share of health resources compared to other OECD countries.
Policy process
Each regional health agency (agence régionale de santé, ARS) defines the composition of GHTs in their area. A specific decree of 27 April 2016 provided the rules for creating GHTs, the governance arrangements to be followed by each group, as well as the scope for pooling functions and activities for implementing a "shared medical project", which will detail the organisation of care for patients by medical specialty. The decree defines a gradual deployment of GHTs to enable facilities to build medical projects on all of their activities. However, it does not provide an indication on the size of GHTs nor the rules for selecting hospitals to work together.
As a starting point, the support or lead facility, nominated in the agreement, will provide a number of functions on behalf of the hospitals included in the group. For example, hospital information systems, the purchasing function, the coordination and development of medical and paramedical training and the continuous professional development of staff will be centralised.
The ARSs were provided three months to define the GHTs in their region (until July 2016). Despite this short time, the deadline was met and 135 GHTs were officially set up in July 2016. However, it is difficult to see the consistency and logic in the composition of GHTs across ARSs. The 135 GHTs are highly variable in nature, ranging from 2 to 20 facilities, and covering from 50,000 to over 2 million inhabitants. Each ARS seems to have its own logic: while some ARSs appear to exploit actual hospital markets (hospitals’ catchment areas) in creating new hospital groups, others use simply administrative borders (department) as units for grouping hospitals, ignoring completely the actual patient move across hospitals and how hospitals compete and collaborate.
To be functional, the GHTs are expected to define concrete projects specifying shared medical services. This work can lead, for example, to the creation of 'territorial medical teams’ (shared between hospitals), advanced medical consultations or joint investments in telemedicine. The GHTs are not expected to be fully operational until 2018 or 2020 in some aspects.
Evaluation
From the current situation, the objective of integrating all public hospitals seems to be largely completed, despite a few exceptions. Very few private hospitals (profit and non-profit) and nursing homes have joined in GHTs until now. However, for GHTs to improve care coordination and pathways of their patients, the collaboration with these structures as well as primary and social care providers may be essential. In any case, it is very early to conclude to what extent the GHTs will improve the efficiency of the hospital sector and whether there would be any perverse effects in terms of access to health care.
Authors
References
Vigneron E (2016). La loi, les GHT et leurs critères d’évaluation. Gestions hospitalières, n° 554
Calvez C (2016). Le Groupement Hospitalier de Territoire (GHT), Dossier Documentaire. Service Documentation EHESP (http://documentation.ehesp.fr, accessed 7 September 2016)
Created by the Law to modernize the health care system of January 2016 (article 107), Territorial Hospital Groups (groupements hospitalier de territoire, GHTs) represent a major reform which will impact both hospital organization and health care delivery. The reform requires public health facilities of a territory to define a shared strategy around a common medical project and jointly manage some cross-functions (information system, purchasing, training plans, etc.). The idea is to improve the cooperation between health care facilities and encourage better management of resources for ensuring continuity of care. GHTs are mandatory for public hospitals but optional for medico-social services and facilities.
A recent decree (27 April 2016) specifies the rules for elaborating GHT’s constitutive agreements, the definition of a shared medical project between hospitals, the modalities of implementation and the scope of functions and activities managed by the “support” facility on behalf of the hospitals being part of the GHT. Each regional agency (agence régionale de santé, ARS) has to define the composition of GHTs in their area by the 1st July 2016.
More information (in French): http://social-sante.gouv.fr/professionnels/gerer-un-etablissement-de-sante-medico-social/groupement-hospitalier-de-territoire/ght
Authors
5.4.1. Day care and other alternatives to full-time inpatient care
Alternatives to full-time inpatient care have been promoted since the late 1980s and encompass: part-time care provided in hospitals (either day or night, including psychiatric care); ambulatory surgery (see above); ambulatory treatments (séances) such as chemotherapy, dialysis, radiation therapy and blood transfusions; HAD; and palliative care.
Of the 26 million hospital stays in 2011, more than half were for less than a day, not including outpatient consultations (DREES, 2013c). Nearly 40% of part-time hospitalizations are for psychiatric care, for which alternatives to full-time inpatient care have been developed since the 1970s. Between 2000 and 2011, the number of part-time places increased by more than 50%, from 16 000 to 36 000, and the density increased from seven to 10 places per 10 000 inhabitants.
Ambulatory treatments, such as chemotherapy and dialysis, are included among the alternatives to full-time hospitalization, although they are not counted as part-time hospitalizations. The vast majority of radiation therapy treatments (96%) are performed in ambulatory care, mostly in private hospitals. The public sector delivers the largest share (51%) of chemotherapy treatments, although the 19 non-profit-making cancer centres (see section 4.1.1) provide significant shares of both chemotherapy (13%) and radiation therapy (21%).
HAD units send medical or paramedical staff to the patient’s home on a daily basis in order to provide continuous and coordinated care in situations where a hospital stay otherwise would have been necessary. This form of intermediate care is targeted at patients with serious, acute or chronic, progressive or unstable disease requiring technical medical care of a certain degree of complexity and/or intensity.
In 2014, HAD units provided a small share (1%) of full-time hospitalizations and 0.5% of SHI expenditure. In 2014, there were 309 HAD units covering all departments, accounting for 4 million days of treatment for 156 000 stays. The government anticipates that this level of activity will double by 2018 (Cour des comptes, 2013b). In 2013, the global cost was €859 million, and an average HAD day costs SHI €196.8 (ATIH, 2014). Nearly one-fifth of HAD places are located in the Paris region (DREES, 2013c). Administratively, HAD units are generally either public hospital departments (42%) or private non-profit-making associations (39%). Each unit is led by a coordinating physician, who is responsible for the overall coordination of medical care, while a coordinating nurse organizes nurse’s rounds for individual treatments. Actual care is provided by salaried staff from the HAD structure or by self-employed professionals. In 2014, HAD care was mainly provided in the areas of complex wound dressings (25.2% of days), palliative care (23.6%), heavy nursing care (11.3%), perinatal care (5.6%) (see section 5.10) and cancer treatment (6.0%), although it included all domains of hospital care, including rehabilitation and psychiatric care. In addition, HAD care has been extended beyond patient homes and since 2007 may be provided in long-term care facilities and other residential facilities, including those for disabled individuals since 2012.