"We are unraveling the public hospital", regrets André Grimaldi

André Grimaldi, diabetologist, has just released the book "Health: emergencies", which makes a diagnosis and offers solutions to help the French health system

André Grimaldi, professor of diabetology at CHU La Pitié-Salpétrière and author of - Odile Jacob

This Friday ends the Ségur de la Santé, six weeks of negotiations between caregivers and the Ministry of Health to design and finance the massive plan for the hospital promised by Emmanuel Macron.
The opportunity to give the floor to André Grimaldi, diabetologist and connoisseur of our healthcare system, who has just published Health: Emergencies .
By giving the floor to 27 doctors and with the help of the sociologist Frédéric Pierru, André Grimaldi draws the contours and challenges of our medicine, which must be modernized while fighting against inequalities and inefficiency.

The alerts are repeated, the caregivers' demonstrations follow each other, the plans accumulate. But nothing helps, France is in pain at its hospital. And yet, the population has never measured their need for free care, foresight, prevention as much as in recent months with the coronavirus crisis. The caregivers, sometimes without equipment, were there. They are now waiting for the president to keep his promise to unveil a massive plan for the public hospital.

Olivier Véran launched on May 25 a "Health Ségur" which ends this Friday. And to go around the challenges of these ambitious negotiations, 20 Minutes interviewed André Grimaldi, professor emeritus of diabetology at the CHU de la Pitié-Salpêtrière,who published the book Santé: urgences * in mid-May . He details his tracks, as well as the point of view of 27 doctors, to revolutionize the health of tomorrow.

Almost two years ago, the strategy for transforming the “My Health 2022” care system was announced. Then the ministry released three plans for emergencies, then the hospital. And yet, the divorce between caregivers and government has only increased. Why you think ?

Minister Agnès Buzyn had made a good diagnosis: we wanted to treat the hospital like a commercial enterprise and we were wrong. This has led to a loss of meaning among professionals. But the actions did not follow the promises. Which is a recurring problem with this government. The President [in March 2020] said: "Health is an opportunity, not a burden". And the Prime Minister inaugurates the "Health Segur" by saying that our diagnosis was the right one, and that we only need to go faster in the reforms.

But this divorce comes from afar. The choice of utilitarian management dates back to 2008 with two things: President Sarkozy declares that all acts of care must pass to user fees, except missions of general interest such as psychiatry. Follow-up of a Bachelot law which implements corporate governance in the public hospital. In addition, the hospital budget will be constrained. We have a monster killing the hospital. The private sector chooses its activities, therefore the most expensive for a clientele that can pay. The public hospital does everything that others don't want.

This Friday ends the Ségur de la Santé, what do you expect?

The wait was before, now is the disillusionment. The first disappointment is the text that summons the Ségur, where the word "public" does not appear once. It was believed that the coronavirus crisis had shown the importance of public service. The real question is the emergency plan called "wages, beds and staff".

Precisely, does the envelope of 6.3 billion, announced by Olivier Véran last week for the revaluation of wages, seem sufficient to you?

Clearly, it is insufficient. We learned little by little that there were 2 billion for the private sector, that it is gross and not clear, that it will vary according to the people. As for the 300 million for doctors and interns, it is paltry. What was also highly anticipated was the hiring. Faced with a private service that pays double, the advantage of the public was the feeling of great freedom, to be up to date, to have cutting-edge tools. If working conditions are much more difficult, why not go private? An even more worrying thing is that the PLFSS is currently being discussed [the Social Security financing bill decides on the budget, notably for hospitals], there is no question of this at all in Ségur. Who decides ? Darmanin and Le Maire or Véran? We are unraveling the public hospital. Irreversibly. The only thing that could change things is a great social crisis, worse than that of the coronavirus.

You write in "Health: emergencies" that the theme of health has so far been addressed during presidential campaigns, which should change for 2022. Why?

Because of the coronavirus. We have been tumbling for years and there, we saw that we were doing much worse than Germany. The United States shows what not to do, but it is towards this model that we are going, a commercial management of health.

Among your ten proposals to refound the public hospital, imagine a public hospital with no longer one, but two directors ...

There are two logics, often in tension: that of care and that of management. The common rule before was to promote good patient care at the lowest cost to the community. We changed that by now saying "it is the profitability of your establishment that we are looking for". The hospital has an interest in doing two MRIs instead of one. This is why we could imagine a two-headed management: a medical director, who has to do with the caregivers very mobilized on the quality of work, staff, teaching and research. And a director of management. Who have to negotiate. In the event of disagreement, a supervisory board may be called upon.

You address another question… How to fight against medical deserts?

Liberal medicine has made the freedom of installation sacred. That neither the nurses nor the pharmacists have. In 1981, Raymond Barre authorized the excess of fees. Freedom which would be difficult to reconsider. But there is one thing that can be done, at the cost of great tension: that a doctor cannot settle in a very dense area when he is overrun. For example, he can open a practice in the 19th arrondissement of Paris, which is a medical desert, but not in the 5th. Second thing, medicine is done as a team. If we want to attract doctors, we need a collective project with good working conditions. One can even imagine two medical competitions, as for the teachers: a path in the public, in a health center, a medical house, a hospital, a university hospital with a ten or fifteen year contract. Another, without obligation.

Third problem: liberal medicine has long opposed the delegation of tasks. Now we need advanced practice nurses, pharmacists who vaccinate. But as long as a general practitioner is paid on a fee-for-service basis, he will not want his diabetic patient to renew his prescription at his pharmacist ...

You explain that to treat chronic diseases, the caregiver must rely on the patient ...

In chronic illness, the patient is an actor in care. To improve compliance, which is only 50%. If you want to help them, you have to understand why they don't follow the protocol. Rather than infantilize them by imposing the wearing of the mask, it is better to ask the question: why you do not put on your mask? It is interesting to propose, in a care team, a patient patient who helps another patient because he has already been there. The patient can identify with him.

France is not very used to betting on public health and prevention. How to fix this wrong?

The 1958 revolution introduced a flagship discipline to the hospital: biology. Today we need to make a new revolution, that of public health, a poor relation in France. Doctors are hostile to it because it is the state. It is complicated because it is a medical discipline, but which requires the assistance of sociologists, psychologists, economists ...

We are emerging from an unprecedented health crisis. What has the coronavirus shown us on our healthcare system?

That public service was essential, that we could not keep the slogan of "flow, no stock". We have measured the damage with the shortage of masks, decisive drugs such as curare, morphine. We have become aware of our dependence on China for medicines. You must have a French or European public establishment which organizes the production of essential medicines.

* Health: emergencies, André Grimaldi and Frédéric Pierru, Odile Jacob, € 23.90, May 2020.

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