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13 December 2024 | Country Update
Expansion of pharmacists’ exceptional right to deliver treatment for chronic conditions beyond the prescription period -
21 October 2024 | Country Update
Pharmacists allowed to deliver antibiotics without a physician’s prescription for specific conditions
5.3. Primary care
Primary care refers to the first level of care and services, including comprehensive general medical care (i.e., acute and chronic care, health promotion, prevention and therapeutic education) for common conditions and injuries, provided in the community near the patients’ place of residence. In France primary care is provided by GPs and some medical specialists practising in ambulatory settings (especially paediatricians, gynaecologists and ophthalmologists), as well as allied health professionals such as dentists, pharmacists, midwives, nurses and physiotherapists.
The responsibility of the local strategy for primary care capacity and investment planning relies on the ARS through a component of SRSs dedicated to ambulatory care (see section 2.3) (Public Health Code of 8 August 2018).
Self-employed primary care physicians are free to choose where and how they practise. This raises issues of access to both primary and specialist care since they are concentrated in well-off urban areas (see Box5.3).
Box5.3
Historically, GPs have worked in solo practices, with limited collaboration with other health professionals. However, in the past decade it has been largely recognized that organizational changes which contribute to better service delivery, such as formal collaboration between different health professionals, are less likely to occur in solo practices. Therefore, France has encouraged different forms of group practice in primary care settings with an appropriate funding model. Despite a slow take-off initially, the proportion of GPs practising in a group has increased regularly over the past decade: 69% of GPs were working in a group practice in 2022, compared to 54% in 2010 (Bergeat, Vergier & Verger, 2022).
Different primary care structures have been created over the past decades through various legal frameworks and payment schemes (Barroy et al., 2014). They include health care centres (Centres de santé) where professionals are salaried, mono-disciplinary group practices (mostly self-employed GPs sharing a private practice) and MSPs where different self-employed primary care professionals share a practice (Afrite & Mousquès, 2014). Traditionally, health care centres mainly provide primary care, but they can also deliver specialist services. MSPs involve self-employed medical and allied health professionals (mostly nurses and physiotherapists), who are paid on an FFS basis (Afrite & Mousquès, 2014). Thus, collaborative work is not usually rewarded in these practices. It was shown that working in MSPs has a positive impact on GPs’ willingness to practise in underserved medical areas (Chevillard & Mousquès, 2021), as well as on productive efficiency and quality of care (Cassou, Mousquès & Franc, 2021; Mousquès & Daniel, 2015).
Therefore, to encourage a shift towards better integration and coordination of care, a new remuneration model providing add-on payments for MSPs (expérimentation des nouveaux modes de rémuneration, ENMR) has been tested since 2010 (see section 3.7.2). The payment, a lump sum per patient, is given to the MSP, which, in return, engages in care coordination and interprofessional cooperation (with a health care project involving all professionals, skill-mix protocols, etc.), as well as improving accessibility (longer opening hours, etc.) and quality of care (following clinical recommendations, better patient information, etc.). These additional payments, initially piloted in a few practices, were generalized for all MSPs in 2015 on a voluntary basis. In 2020 there were 1612 MSPs registered (1300 new MSPs since 2008) and more than 50% of them benefited from the additional payments (Cassou, Mousquès & Franc, 2021). During the Covid-19 crisis health professionals working in group practices appeared to demonstrate more resilience in assuring continuity of care, with higher rates of remote consultations and patient follow-up procedures than traditional solo practices (Zaytseva, Verger & Ventelou, 2021).
The 2016 health reform law has also supported the development of health professional communities at the local level (Law no. 2016-41 of 26 January 2016). Local health professional communities (Communautés professionnelles territoriales de santé, CPTS) are voluntary networks of health care professionals, from the primary, secondary and LTC sectors, who come together to develop a common medical project for attaining specific public health objectives, improving care coordination and evaluation at the local level. They are granted an associative status and can contract with ARS and local SHI funds, and they set objectives at the population level rather than for a given patient list. Currently, the objectives concern mostly better care protocols rather than patient outcomes. In 2021, 670 CPTS were registered (FCPTS, 2021) but their level of implementation remains variable. Their creation is associated with an important administrative burden which may be a barrier to their development, and an assessment of their organization is necessary to increase local efficiency in the longer term (HCAAM, 2022a).
Compared to many other European countries, nurses and other allied health professionals have little responsibility and power in primary care provision in France. This is partly because each professional has legally defined tasks and procedures that they can deliver and professionals are paid by FFS (Brissy, 2020). Therefore, attempts to promote task transfer from physicians to other professionals, such as nurses, have had little success. However, in recent years the roles and responsibilities of allied health professionals have been extended for strengthening primary care provision. New positions (such as medical assistants for GPs) were created in 2019 and the competences of allied health professionals, especially nurses, were scaled up (see section 4.2.2). Moreover, since 2019, following successful local pilots, pharmacists are allowed to carry out flu vaccinations (France is one of the last countries in Europe to allow pharmacists to vaccinate patients). Since 2021 patients can also choose an “attending pharmacist” (Pharmacien correspondant), who is part of the local multiprofessional care team. Attending pharmacists are allowed to renew prescriptions and adapt the dosages for their patients (Decree no. 2021-685 of 28 May 2021) and follow up specific patient groups (such as persons with asthma or oral anticoagulant prescriptions) (ONDPS, 2021). The Covid-19 pandemic has consolidated the new responsibilities given to pharmacists as they have been instrumental, first in coordinating the distribution of protective equipment to health professionals, then in providing antigen tests and Covid-19 vaccinations (Gandré & Or, 2021). These new measures give community pharmacists an enhanced role in primary care, which can help facilitate access to care in medically underserved areas (OECD, 2020c). Other health professionals in the primary care sector, in particular nurses and physiotherapists, remain dependent on physicians, as their services have to be prescribed by a physician to be reimbursed. Recent reforms have, however, allowed direct access to orthoptists for specific categories of patients and direct access to speech therapists and physiotherapists working in MSPs. Finally, the prescription by advanced nurses of some procedures which were previously only available upon a medical prescription will also be tested in three regions (Law no. 2021-1754 of 23 December 2021).
Authors
References
Décret n° 2024-1070 du 26 novembre 2024 relatif à la dispensation supplémentaire exceptionnelle de médicaments et de dispositifs médicaux dans le cadre d’un traitement chronique – Légifrance: https://www.legifrance.gouv.fr/jorf/id/JORFTEXT000050668009
In 2023, the Social Security Financing Act introduced the possibility for community pharmacists to deliver antibiotics for specific conditions without a physician’s prescription, provided that they had undergone a four-hour training program. This measure has been implemented by decree since June 2024. These specific conditions include streptococcal bacterial throat infection (group A streptococcal infection) and acute uncomplicated cystitis in women. The dispensing of antibiotics by pharmacists for these two conditions is contingent upon the positivity of a rapid diagnostic orientation test (swab test or urinary test based on the suspected condition) and the absence of any indication of severity or emergency of illness in the patient. This measure aims to support task shifting from general practitioners to pharmacists for the care of common infections, particularly in medically underserved areas where it can be challenging to secure a prompt appointment with a general practitioner. Additionally, it aims to reduce the misuse of antibiotics by ensuring that they are only delivered when the requisite criteria are met.
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