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27 July 2023 | Country Update
Direct access to selected allied health professionals
5.2. Patient pathways
In France there is no compulsory gatekeeping, but the 2004 SHI reform encourages patients to choose a “referring physician” (Médecin traitant) – a GP or a specialist – who should act as a gatekeeper. In practice, patients are expected to see their referring physician before visiting a specialist physician (Fig5.1), otherwise the SHI reimburses only 30% of the regulated consultation fee (instead of 70%) (CNAM, 2021c). There are a few exceptions: patients under 16 years old are not subject to these rules and patients are allowed to visit some specialists without GP referral. This is the case for gynaecologists, ophthalmologists, psychiatrists (for patients aged 16–25 years) and stomatologists (for minor procedures only) (CNAM, 2022e). Direct access to physiotherapists working in MSPs has also been piloted at the local level since 2022, while a similar pilot is under discussion for IPAs (Bruant-Bisson, Laffon & Marty, 2021). According to the SHI fund, about 90% of the insured declare a “referring physician”. Therefore, most of the time the first point of contact with the health system is a GP (or paediatrician for minors), who follows up patients and provides referrals when necessary (see Box5.2). There is no need for a referral to access inpatient hospital care, but usually patients are referred by outpatient specialists or generalists or go through hospital emergency departments (service d’urgence, ED). Rehabilitation after hospitalization can take place in post-acute and rehabilitation facilities (either in inpatient or outpatient settings) or is provided by self-employed physiotherapists in the community or at the patient’s home. Patients can freely choose their health care provider (in the private or public sector) throughout the care pathway, with possible extra-billing by some providers (see section 3.7.1).
| Fig5.1 | Box5.2 |
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The lack of coordination between ambulatory, hospital and social care has long been recognized as a major drawback both in terms of cost control and quality of care (Larcher, 2007). The fact that most providers work independently – with little collaboration between hospital, primary and social care services – means that care is fragmented and patients need to navigate a complicated system. Moreover, uncoordinated care, coupled with the high degree of independence and choice both for providers and patients, has been identified as a key driver of health care costs (Or & Gandré, 2021).
Strengthening care coordination between different specialists as well as between specialists and other care providers, including LTC providers, has become a policy priority due to a growing number of patients with multiple diseases. To improve continuity and coordination of care across different settings, recent policies aim to improve care pathways considering the principle of gradation of care. The gradation of care is the organization of care processes that meet these objectives: the delivery to everyone, at the right time, of the “right care”, the “right response” according to their needs (HCAAM, 2020a). In this new approach the regular follow-up of patients with chronic conditions should take place in primary care with ad hoc advice from specialists when necessary, while more complex conditions are treated by specialists, in or out of hospitals (HCAAM, 2020a).
A law adopted in May 2023 extends the list of healthcare professionals that patients can access without GP referral. Following this new regulation, patients have now direct access to advanced nurse practitioners, physiotherapists and speech therapists who are working in coordinated care practices such as hospitals, clinics, medico-social establishments, multidisciplinary group practices or healthcare centres. This measure aims to tackle the persistent problem of underserved medical areas by easing access to healthcare.
The law also supports task shifting, as it is extending the remit of several allied health professionals. Advanced nurse practitioners will notably be able to initiate the prescription of specific drugs or procedures, and opticians will be allowed to adapt glasses and contact lens prescriptions.
This law was adopted following long and difficult discussions in the two parliament chambers. Additionally, both physicians and allied healthcare professionals have claimed that the new law is not providing enough support for their respective roles within the healthcare system.
More information available here (in French): https://www.assemblee-nationale.fr/dyn/16/dossiers/amelioration_confiance_professionnels; https://www.vie-publique.fr/loi/288203-acces-aux-soins-loi-rist-du-19-mai-2023